Citation Nr: 1751175 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 13-13 182 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). ORDER Service connection for an acquired psychiatric disability, to include posttraumatic stress disorder, is denied. FINDINGS OF FACT The Veteran does not have a current diagnosis of PTSD; symptoms of an acquired psychiatric disability other than PTSD were not continuous or recurrent in service and have not been continuous or recurrent since service separation; psychosis did not manifest within one year of service separation; and there is no medical nexus between the current psychiatric disability and active service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disability, to include PTSD, have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.384 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran, who is the Appellant in this case, had active service from January 2006 to January 2010. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a September 2012 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). In February 2017, the Board remanded the case for the RO to schedule a Travel Board hearing. Subsequently, the Veteran provided testimony at a May 2017 Travel Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is associated with the claims folder. 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. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) competent evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that "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." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as psychosis (e.g., schizophrenia and schizoaffective disorder), to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In this case, the medical evidence of record demonstrates a current diagnosis of psychosis. Where the veteran asserts entitlement to service connection for a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service or diagnosis within the presumptive period after service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013); 38 C.F.R. § 3.307 (service connection authorized for chronic diseases diagnosed within the presumptive period). However, for the reasons set forth below, the Veteran was not diagnosed with a psychosis within one year of separation from service, nor has there been continuity of symptomatology. With specific regard to continuity of symptomatology, for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition, such as psychosis, noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). The remaining psychiatric diagnoses at issue are not any of the "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.309(b) (requiring continuity of a condition after service if chronicity is not found in service) does not apply to those disorders. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also 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). 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. See 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); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. At 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a 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. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran contends that he has PTSD that is related to active service. Namely, he states that, during boot camp, his instructors repeatedly hit him in the head over the course of multiple weeks, and that when he reported the abuse, his commanding officer and other military officials covered the incident up. In addition to the laws and regulations outlined above, service connection for PTSD requires: medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (conforming to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). With regard to the first element necessary for a grant of service connection for PTSD (medical evidence of PTSD), the Board finds that the weight of the evidence is against a finding that there is a current diagnosis of PTSD. The first requirement for any service connection claim is competent evidence of existence of a current disability. Brammer, 3 Vet. App. at 225. The Veteran was afforded a VA examination in August 2012, and the VA examiner found that he did not have a diagnosis of PTSD that conformed to the DSM-IV criteria. The examiner instead diagnosed anxiety disorder NOS. Specifically, the examiner found that, while the claimed in-service stressor met criterion A (adequate to support a diagnosis of PTSD), the traumatic event was not persistently re-experienced (criterion B), there was no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (criterion C), the Veteran had only one of the two required symptoms under criterion D (irritability or outbursts of anger), and criteria E (duration of symptoms) and F (PTSD symptoms cause clinically significant distress or impairment) were not met. The Board notes that the Veteran's VA treatment notes do include PTSD in the computerized list of problems and that several providers list PTSD as a diagnosis (e.g., outpatient treatment note dated May 25, 2012). However, an important basis for weighing various references to PTSD is the purpose for which they are recorded. This can generally be surmised from the context of report. See Lee v. Brown, 10 Vet. App. 336 (1997) (a medical opinion should be viewed in its full context, and not characterized solely by the medical professional's choice of words). Simple references in the medical record that the Veteran is being followed for PTSD or noting a diagnostic history of PTSD are not presented as comprehensive diagnoses, but are presented typically in summary or list format to give treatment providers an overview of the Veteran's various disorders, and in some cases, the medications prescribed for each. Such non-diagnostic references may be based on a discussion with the Veteran or based on a review by the clinician of the Veteran's treatment records. In a voluminous record such as this one, the variances in diagnoses, preliminary diagnoses, and questioned diagnoses undoubtedly increases the likelihood of a disconnect between these informational references and the concurrent consensus of his psychiatric treatment providers as to his actual diagnosis. Indeed, in this case, it appears that the notation of treatment for PTSD symptoms was used as an informational reference for the type of treatment the Veteran was receiving and as a description of some of his symptoms rather than a formal diagnosis. Moreover, none of the references to PTSD as a diagnosis indicate that the diagnosis was made using DSM-IV or V criteria. Indeed, in a June 2012 VA treatment note, a nurse noted that, based on the Veteran's responses on the PTSD Checklist (a self-report scale to measure PTSD symptoms), criterion C for a diagnosis of PTSD under the DSM-IV criteria was not met, yet, regardless, the nurse listed PTSD as a diagnosis along with depression. Further, in this case, multiple treating and evaluating physicians, including his VA treating psychiatrist, have not diagnosed PTSD after thoroughly noting his history of PTSD symptoms and discussing his claimed PTSD stressor (see, e.g., Mental Health Intake Assessment dated October 11, 2012; Discharge Summary dated June 5, 2013; Social Work Note dated June 11, 2013; and treatment notes signed by VA psychiatrist dated July 8, 2013, August 13, 2013, October 15, 2013, April 9, 2014, July 21, 2014, October 1, 2014, November 17, 2014, January 13, 2015, February 11, 2015, June 24, 2015, August 26, 2015, December 29, 2015, and March 29, 2016). The question that must be determined is whether there is a diagnosis of PTSD at any time since the claim was filed. McClain v. Nicholson, 21 Vet. App. 319 (2007) (the presence of a disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative). The references to PTSD in the VA treatment notes in this case are not interpreted as a finding that PTSD is a current disability, or that it has been present at any specific time pertinent to the appeal. This finding is further supported by the conclusions of the August 2012 VA examiner, who opined that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD, as well as the VA treating psychiatrist, who spent extensive time interviewing and evaluating the Veteran, yet did not diagnose PTSD at any time, as noted above. Accordingly, the Board finds that the greater weight of the probative evidence is against finding that the Veteran has a current diagnosis of PTSD. Thus, in specific reference to the PTSD aspect of the appeal, the Board reiterates that in the absence of proof of a present disability there can be no valid claim. Brammer. As a result, the claim for service connection for PTSD is denied. As above, the Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain, 21 Vet. App. 319. However, where the overall record fails to support a current diagnosis of the claimed disability, as is the case here, that holding would not apply. The Board has considered the Veteran's statements regarding his symptoms, and acknowledges that he is competent to give evidence about what he experienced; for example, he is competent to discuss his irritability and other experienced symptoms. See Layno, 6 Vet. App. 465. However, in the present case, although his irritability and other symptoms are found to be capable of lay observation, the diagnosis of PTSD is not within the province of a layperson, as such a diagnosis requires psychiatric testing and evaluation by a mental health professional, and thus his statements to the effect that he has a diagnosis of PTSD do not constitute competent evidence. Given the lack of a current diagnosis of PTSD, the Board finds that the preponderance of the evidence is against the Veteran's claim of service connection for PTSD. For these reasons, the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Next, the Board has considered whether service connection for any psychiatric disability other than PTSD is warranted. Service treatment records are negative for signs, symptoms, findings, treatment, or diagnosis of any psychiatric disability. At a Periodic Health Assessment in July 2007, the Veteran checked "no" next to "nervous trouble of any sort," and "depression or excessive worry" on his Report of Medical History. At Periodic Health Assessments in July 2008 and November 2008, no referral was made for mental health and the Veteran did not report any related complaints. Further, the November 2009 separation examination report indicates a normal psychiatric evaluation, and the Veteran checked "no" next to "nervous trouble of any sort," and "depression or excessive worry" on his Report of Medical History, providing highly probative evidence against the current claim that a psychiatric disability had its onset during active service. Following separation from service in April 2010, a VA treatment note indicates that the Veteran had positive PTSD and depression screens, and that he reported flashbacks and nightmares related to the military. However, no diagnosis or mental health treatment was rendered at that time. In December 2010, the Veteran was afforded a VA general medical examination as part of his claim for service connection for multiple non-psychiatric-related disabilities. He denied experiencing any psychiatric symptoms, including interpersonal relationship difficulties, depression, panic attacks, memory problems, loss of control or violence potential, anxiety, and sleep impairment. Psychiatric examination also revealed normal affect, mood, judgment, and appropriate behavior, with no obsessive behavior or hallucinations/delusions. This document weighs against a grant of the current claim, as it tends to show that psychiatric symptoms have not been continuous or recurrent since service separation. In October 2011, the Veteran sought treatment for symptoms of depression, citing to difficulties reinstating his driver's license and associated legal problems over the past two years. He was diagnosed with depression. In December 2011, he specifically attributed his feelings of depression to his inability to get his driver's license back, weighing against the current claim. In May 2012, he reported to the emergency department after experiencing a mental breakdown during which he became emotional while at the bank and began telling the bank employee about his physical abuse during active service. It was recommended that he follow up with a psychiatrist as an outpatient for continued management of his depression and evaluation for possible PTSD. As noted above, he was afforded a VA examination in August 2012, and was diagnosed with anxiety disorder NOS. Notably, he told the examiner that he first sought mental health treatment in January 2012 for feelings of depression and anxiety over not having a job, weighing against a finding of a nexus to military service. He then stated that he sought treatment again in June 2012 after he thought about his military experiences and became very upset. Based on a review of the claims file and the history provided by the Veteran, the VA examiner opined that his anxiety was less likely than not related to his military experiences, but rather, was likely related to his lack of employment and good social support. In October 2012, a social worker conducted a Mental Health Intake Assessment. The Veteran's claimed stressors and symptoms were thoroughly discussed, and the social worker diagnosed rule out bipolar disorder NOS. The Veteran was hospitalized in May 2013 for increasing violent behavior and rages, particularly in the prior month. It was noted that the Veteran had begun threatening his family members, that he was fixated on government corruption and perceived injustice by the police against him. His discharge diagnoses were psychosis NOS, mood disorder NOS, marijuana abuse, rule out substance-induced mood disorder, rule out substance induced psychosis, and rule out bipolar disorder NOS. VA treatment notes indicate that the Veteran continued to meet with his treating psychiatrist, who diagnosed psychosis NOS, rule out schizoaffective disorder, and rule out schizophrenia. More recent treatment notes indicate that the current diagnoses using DSM-V criteria is unspecified psychotic disorder and hallucinogen use disorder, remission. After a review of the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that an acquired psychiatric disability did not have its onset during active service. As noted above, the service treatment records provide highly probative evidence against such a finding, in particular the November 2009 separation examination report. The Board also finds that the preponderance of the evidence demonstrates that a psychosis did not manifest to a compensable degree within one year of service separation. The preponderance of the evidence demonstrates no psychosis during the one year period after service; and no diagnosis or findings of psychosis of any severity during the one year post-service presumptive period. See 38 C.F.R. § 4.130, Schedule of Ratings for Mental Disorders. Indeed, the evidence does not demonstrate a diagnosis of a psychosis until 2013, when the Veteran was diagnosed with psychosis during his hospitalization, as described above. For these reasons, the Board finds that a psychosis did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for psychosis are not applicable in this case. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Next, the Board finds that the weight of the evidence is against a finding that the Veteran's current psychiatric disability, variously diagnosed as anxiety, depression, psychosis, schizoaffective disorder, and schizophrenia, is related to active service. Symptoms of a psychiatric disability have not been continuous or recurrent since service separation in January 2010. Following service separation in January 2010, the evidence of record shows no mention of psychiatric symptoms until April 2010, as described above, and even then, no diagnosis or treatment was rendered. The absence of post-service complaints, findings, diagnosis, or treatment for four months after service separation until April 2010 is one factor that tends to weigh against a finding of continuous symptoms of a psychiatric disability after service separation. See Buchanan (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Other evidence of record showing that symptoms of an acquired psychiatric disability were not continuous or recurrent since service includes the negative December 2010 VA examination report, including the Veteran's own statements denying any psychiatric symptoms. This report, in particular, provides highly probative evidence against a finding of psychiatric symptoms since active service. The examination was conducted to determine whether the Veteran's various claimed disabilities were related to active service, so it is assumed that he would have reported any psychiatric symptoms he believed were related to active service during that examination; his failure to do so weighs heavily against the current claim. In addition, when the Veteran sought treatment for psychiatric symptoms in October 2011, he attributed his symptoms to his legal problems and not to active service, providing highly probative evidence against a finding of continuous symptoms since active service or a nexus to active service. As noted above, while the Veteran is competent to report the onset of his psychiatric symptoms, his more recent assertions made in the context of the current disability claim of continuous or recurrent psychiatric symptoms since service are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles, 16 Vet. App. 370. The Board finds that the Veteran's assertion of continuous or recurrent psychiatric symptoms after service is not accurate because it is outweighed by other evidence of record that includes the more contemporaneous service separation examination report which shows a normal psychiatric evaluation and at which the Veteran specifically denied psychiatric symptoms; the negative VA examination report conducted in December 2010, less than one year after service separation; the lack of any documentation of reports or treatment for psychiatric symptoms until April 2010; and the treatment notes from October 2011 indicating psychiatric symptoms related to legal problems. As such, the Board finds that the evidence does not sufficiently support continuous or recurrent psychiatric symptomatology since service so as to warrant a grant of service connection. The Board acknowledges the Veteran's belief that his current psychiatric disability is related to active service, as well as his father's June 2017 statement to the effect that he believes his son's symptoms are related to military service. However, their statements alone do not establish a medical nexus. Indeed, as noted above, while the Veteran and his father are competent to provide evidence regarding matters that can be perceived by the senses, neither is shown to be competent to render medical opinions on questions of etiology. See Jandreau, 492 F.3d 1372; see also Barr, 21 Vet. App. 303 (lay testimony is competent to establish the presence of observable symptomatology). As such, as a lay person, they are without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that neither the Veteran nor his father is competent to address. Jandreau. Moreover, the Board finds that no competent medical opinions are of record which support a relationship between the Veteran's claimed psychiatric disability and active service, nor is there any other indication in the medical evidence of record that there is a relationship between the claimed psychiatric disability and active service. Indeed, as discussed above, the August 2012 VA examiner opined that the Veteran's current psychiatric symptoms and diagnoses are less likely than not related to or incurred during his military service. This opinion was based on a thorough interview and evaluation of the Veteran as well as review of his claims file, including his service treatment records and post-service treatment records, and, therefore, is considered highly probative by the Board. There are no contrary opinions of record. With regard to the Veteran's substance abuse disorders, the Board notes that direct service connection for disability resulting from a claimant's own drug or alcohol abuse is precluded for all VA benefit claims filed after October 31, 1990. See VAOPGCPREC 7-99; VAOPGCPREC 2-98. Compensation cannot be awarded pursuant to 38 U.S.C. §§ 1110 and 38 U.S.C. § 105(a) either for primary alcohol abuse disabilities or for secondary disabilities that result from primary alcohol abuse. Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). In this case, the evidence of record does not suggest that an alcohol or drug abuse disability is secondary to, or a symptom of, a service-connected disability. Based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's current psychiatric disabilities and his military service, including no credible evidence of continuous or recurrent symptoms of the claimed disabilities during active service, or continuous or recurrent symptomatology of the claimed disabilities following service separation. Further, the weight of the medical evidence demonstrates that there is no link between the claimed disabilities and active service. Therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for an acquired psychiatric disability, and outweighs the Veteran's more recent contentions regarding in-service continuous or recurrent symptoms and continuous or recurrent post-service symptoms. For these reasons, the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by way of a July 2012 letter, as well as the September 2012 rating decision and March 2013 statement of the case; the Veteran had multiple subsequent opportunities to submit additional evidence, and there was no prejudice to the Veteran in any untimeliness in notice. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, service personnel records, post-service VA and private treatment records, a VA examination and opinion, and the Veteran's statements, including his testimony at the May 2017 Board hearing. The Court held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts 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. Here, during the May 2017 Board hearing, the undersigned Veterans Law Judge asked questions pertaining to the criteria necessary for establishing his claim, including regarding specific evidence that may help substantiate his claim. Moreover, neither the Veteran, nor his representative, has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. 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 any error in notice provided during the hearing constitutes harmless error. As discussed above, a VA examination was conducted in August 2012. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the August 2012 VA examination obtained in this case is adequate. The opinion was predicated on a full reading of the private and VA medical records in the Veteran's claims file as well as an in-person interview of the Veteran. The VA nexus opinion considered all of the pertinent evidence of record, to include VA treatment records, comprehensive physical examinations, and the statements of the Veteran, and provides a complete rationale for the opinion stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). Notably, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD T. Sherrard, Counsel Copy mailed to: The American Legion Department of Veterans Affairs