Citation Nr: 1801475 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 12-23 981 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee THE ISSUE Entitlement to service-connected burial benefits. REPRESENTATION Appellant represented by: Tennessee Department of Veterans' Affairs WITNESSES AT HEARING ON APPEAL Appellant and her son ATTORNEY FOR THE BOARD B. Elwood, Counsel INTRODUCTION The Veteran served on active duty from November 1954 to November 1956. He died in December 2010. The appellant is his surviving spouse. This appeal to the Board of Veterans' Appeals (Board) arose from an April 2011 rating decision in which the RO in Milwaukee, Wisconsin, inter alia, denied service-connected burial benefits. In May 2011, the appellant filed a notice of disagreement (NOD) limited to that issue. A statement of the case (SOC) was issued in June 2012, and the appellant filed a statement accepted in lieu of a substantive appeal (VA Form 9, Appeal to the Board of Veterans' Appeals) in August 2012. During the pendency of the appeal, the claims file was transferred to the jurisdiction of the RO in Nashville, Tennessee, which certified the appeal to the Board. In March 2014, the appellant and her son testified during a Board video-conference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record. In January 2015 and, again, in April 2017, the Board remanded the claim for service-connected burial benefits to the agency of original jurisdiction (AOJ) for further development. After completing the requested development, the AOJ continued to deny the claim (as reflected in May 2016 and September 2017 supplemental SOCs (SSOCs)), and returned this matter to the Board for further appellate consideration. Also, while the Veteran previously had a paper claims file, this appeal is now fully being processed utilizing the paperless, electronic Veterans Benefits Management System (VBMS) and Virtual VA (Legacy Content Manager) claims processing systems. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim herein decided have been accomplished. 2. The Veteran died in December 2010; his death certificate indicates that the immediate cause of death was cardiopulmonary arrest due to, or as a consequence of, end stage heart disease. 3. At the time of the Veteran's death, service connection had been established for triple arthrodesis of the left foot, rated as 30 percent disabling from February 3, 1971; he had also been awarded compensation pursuant to the provisions of 38 U.S.C. § 1151 for bilateral peripheral neuropathy of both upper and lower extremities,. 4. No cardiac disability was shown during active service or for years thereafter and the most persuasive medical opinion evidence of record weighs against a finding that there existed a medical relationship, or nexus, between the Veteran's fatal cardiac disability and service. 5. A preponderance of the competent medical evidence weighs against the claim that the Veteran's service-connected triple arthrodesis of the left foot caused or contributed substantially or materially to cause his death. 6. As service connection for the Veteran's cause of death has not been established, service-connected burial benefits may not be awarded. CONCLUSION OF LAW The criteria for service-connected burial benefits are not met. 38 U.S.C. §§ 1110, 1131, 1310, 2302, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.312, 3.159, 3.1600 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2017). After a complete or substantially complete application for benefits is received, notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Pelegrini v. Principi, 18 Vet. App. 112 (2004) and Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the appellant here is seeking VA burial benefits, adjudication of the matter of service connection for the cause of the Veteran's death for purposes of such benefits requires consideration of notice requirements pertinent to claims for Dependency and Indemnity Compensation (DIC) benefits. In a claim for DIC benefits based on service connection for the cause of a veteran's death, VA's notice requirements include (1) a statement of the conditions, if any, for which a veteran was service-connected at the time of his or her death; (2) an explanation of the evidence and information required to substantiate a DIC claim based on a previously service-connected condition; and (3) an explanation of the evidence and information required to substantiate a DIC claim based on a condition not yet service-connected. Hupp v. Nicholson, 21 Vet. App. 342 (2007). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, a March 2011 pre-rating letter provided notice to the appellant regarding the disabilities for which the Veteran was service-connected at the time of his death and what information and evidence was needed to substantiate a claim based on service connection for the cause of the Veteran's death due to both a previously service-connected disability and disabilities not yet service-connected (consistent with Hupp). The March 2011 letter also provided the appellant with information pertaining to the assignment of effective dates, as well as the type of evidence that impacts that determination. The April 2011 rating decision reflects the RO's initial adjudication of the appellant's service-connected burial benefits claim after issuance of the March 2011 letter. Hence, this letter generally meets Pelegrini's and Dingness/Hartman's content of notice and timing requirements. The Board notes that the appellant did not receive any notice pertaining to the assignment of disability ratings. Nevertheless, as no rating is being assigned in this case, she is not prejudiced by the deficiency with regard to this element. The record also reflects that, consistent with applicable duty-to-assist provisions, VA has made reasonable efforts to develop the appellant's claim, to include obtaining or assisting in obtaining all relevant records and other evidence pertinent to the matter herein decided. Pertinent evidence associated with the claims file consists of the Veteran's service treatment records, the Veteran's death certificate, VA treatment records, private medical records, and VA medical opinions which address the nature and etiology of the Veteran's cause of death. Also of record and considered in connection with the appeal are the transcript of the March 2014 Board hearing, along with various written statements submitted by the late Veteran, as well as by the appellant and her representative, on her behalf. The Board finds that no further development on the claim herein decided, prior to appellate consideration, is required. As for the March 2014 Board hearing, it is noted that, during the hearing, the appellant appeared, along with her son and authorized representative, and provided testimony on the burial benefit matter herein decided. At that time, the undersigned VLJ identified the single burial benefit issue on appeal. With respect to this issue, information was elicited regarding why it was believed that the Veteran's cause of death was related to service. The VLJ also explicitly suggested that the appellant attempt to obtain a medical opinion addressing whether a service-connected disability contributed to the Veteran's death. Moreover, the hearing testimony revealed the need for additional development, which was sought on subsequent remands. Thus, the hearing was legally sufficient. See 38 C.F.R. § 3.103 (c)(2) (2017); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board also finds that, relative to the claim herein decided, there has been substantial compliance with the Board's January 2015 and April 2017 remand directives. See Dyment v. West¸ 13 Vet. App. 141, 146-47 (1999); see also D'Aries v. Peake, 22 Vet. App. 97, 105-106 (2008). The Board directed that the AOJ obtain all outstanding VA treatment records from the VA Medical Center (VAMC) in Memphis, Tennessee dated from June 1999 to December 2010, request that the appellant identify any outstanding treatment records and complete the appropriate authorization so as to allow VA to obtain any outstanding private treatment records (to include pertinent records from Baptist Memorial Hospital), obtain any outstanding private treatment records identified by the appellant, and obtain medical opinions pertaining to the nature of any relationship between the Veteran's cause of death and service and his service-connected triple arthrodesis of the left foot. VA medical opinions pertaining to the etiology of the Veteran's cause of death were obtained in May 2016 and August 2017 and all outstanding VA treatment records have been obtained and associated with the claims file. Also, in February 2015 and May 2017 letters, the AOJ requested that the appellant identify any outstanding treatment records and complete the appropriate authorization so as to allow VA to obtain any outstanding private treatment records (to include records from Baptist Memorial Hospital). In response to the February 2015 letter, the appellant submitted treatment records from Baptist Memorial Hospital to the AOJ, but the majority of these records are of poor quality and unreadable. She did not identify or submit any other outstanding treatment records and has not completed the appropriate authorization form so as to allow VA to obtain any outstanding private treatment records (to include the records from Baptist Memorial Hospital). VA is only required to seek pertinent records that are adequately identified and for which necessary releases are furnished. 38 U.S.C. § 5103A (b); 38 C.F.R. §§ 3.159 (c)(1)(i), (c)(2)(i) (requiring a claimant to cooperate fully with VA's efforts to obtain federal and non-federal records); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (the duty to assist is not always a one-way street). Thus, VA has no further duty to attempt to obtain any additional treatment records. In summary, the duties imposed by the VCAA have been considered and satisfied. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the matter herein decided. As such, the appellant is not prejudiced by the Board proceeding to a decision on this claim, at this juncture. See Mayfield v. Nicholson, 20 Vet. App.539, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis A burial allowance is payable under certain circumstances to cover the burial and funeral expenses of a veteran and the expense of transporting the body to the place of burial. 38 U.S.C. § 2302; 38 C.F.R. § 3.1600. If a veteran dies as a result of a service-connected disability or disabilities, certain burial benefits may be paid. 38 C.F.R. § 3.1600 (a). As noted in the Introduction section above, this appeal originates from the appellant's claim for burial benefits. In April 2011, the RO awarded nonservice-connected burial benefits, but denied entitlement to greater, service-connected burial benefits on the basis that the Veteran's death was not related to service. The RO also separately denied service connection for the cause of the Veteran's death. In May 2011, the appellant filed an NOD as to the denial of service-connected burial benefits. Since the critical inquiry in determining whether service-connected burial benefits are warranted is whether the Veteran's death is service-related, the Board's analysis will focus on the question of whether service connection is warranted for the cause of the Veteran's death. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). With chronic disease shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic, or when the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that the provisions of 38 C.F.R. § 3.303(b) pertaining to the award of service connection on the basis of continuity of symptomatology apply only to chronic diseases as defined in 38 C.F.R. § 3.309(a) (2017). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). To establish entitlement to service connection for the cause of the Veteran's death, the evidence of record must show that a disability incurred in or aggravated by service either caused or contributed substantially to his death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. Service-connected disability will be considered as the principal cause of death when such disability, singly or jointly with another condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b). To be considered a contributory cause of death, it must be shown that service-connected disability contributed substantially or materially; that it combined to cause death; or that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c)(1). It is not sufficient to show that service-connected disability casually shared in producing death; rather, a causal connection must be shown. Id. Laypersons, such as the appellant, are competent to report on matters observed or within his or her personal knowledge, to include the occurrence of injury, and as to the nature, onset, and continuity of symptoms experienced or observed. See 38 C.F.R. § 3.159 (a)(2); Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board, however, retains the discretion to determine the credibility and probative value of all evidence of record, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. In this case, the evidence reflects that the Veteran died in December 2010. His death certificate lists the immediate cause of death as cardiopulmonary arrest, due to or as a consequence of end stage heart disease. There were no other conditions listed as contributing to the Veteran's death. At the time of his death, service connection had been established for triple arthrodesis of the left foot, rated as 30 percent disabling from February 3, 1971. The Board points out that the Veteran was also in receipt of VA compensation under 38 U.S.C. § 1151 (2012) for neuropathies of the bilateral upper and lower extremities. However, a claim for service-connected burial benefits cannot be premised on disabilities compensated "as if" service-connected under 38 U.S.C. § 1151. See Mintz v. Brown, 6 Vet. App. 277, 282-83 (1994). Hence, in order to award service-connected burial benefits in this case, the evidence must establish either that the service-connected triple arthrodesis of the left foot caused or contributed substantially to the Veteran's death, or that the principal or contributory cause of his death was otherwise due to a disease or injury incurred in or aggravated by service. The appellant contends, in effect, that the Veteran's service-connected disabilities put undue stress on his heart and caused or substantially contributed to his death from cardiac arrest. Notably, the Veteran had also contended in an April 1999 statement (on a VA Form 21-4138, Statement in Support of Claim) that his heart problems were due to the fact that his ability to walk and exercise were limited by his foot and leg problems. The appellant and the Veteran appear to include in their contentions the neuropathies for which the Veteran was in receipt of compensation under 38 U.S.C. § 1151; which, as noted, cannot serve as the basis of an award of service-connected burial benefits under applicable law. After a full review of the record, including the medical evidence, as well as statements by the appellant and those made on her behalf, the Board finds that service connection for the cause of the Veteran's death has not been established and that, therefore, service-connected burial benefits may not be awarded. There is no evidence of any complaints of or treatment for any cardiac problems in the Veteran's service treatment records and his September 1956 separation examination was normal, other than a notation of occasional wheezes. The appellant has not reported, and the evidence does not otherwise indicate, a continuity of symptomatology with regard to the Veteran's fatal cardiac disability. The evidence otherwise indicates that the Veteran's fatal cardiac disability did not manifest until many years following service. The earliest post-service evidence of cardiac symptoms is contained in an April 1998 VA Preanesthetic Summary report which reveals that the Veteran experienced a myocardial infarction in 1987. There is no lay or clinical evidence of any earlier cardiac symptoms following service. The absence of any lay or clinical evidence of cardiac problems for over three decades after the Veteran's separation from service in November 1956 weighs against a finding that his fatal cardiac disability was present in service or in the year or years immediately after service. Hence, neither the clinical record nor the lay statements of record establish a continuity of symptomatology in this case. Moreover, the only competent, probative medical opinions to address the matters at the crux of this appeal-whether the fatal cardiac disability was related to service, or whether the Veteran's service-connected triple arthrodesis of the left foot caused or contributed substantially or materially to cause his death-weigh against the claim. In May 2016, a VA physician reviewed the Veteran's claims file and explained that the Veteran was service-connected for triple arthrodesis of the left foot. He had sprained his foot in service in 1955 and further injured it playing softball in 1971. In March 1971, he underwent a triple arthrodesis for traumatic calcaneal bar on the left foot and ambulated with orthotic shoes after the surgery. The physician noted that the Veteran had a myriad of medical conditions when he died, including the following: coronary artery disease, status post coronary artery bypass graft; atrial fibrillation; congestive heart failure; abdominal aortic aneurysm; cervical cord compression at C3-4; gastroesopheal reflux disease (GERD); carpal tunnel syndrome; vitamin B 12 deficiency; hypertension; post laminectomy of the lumbar spine; peripheral neuropathy; and chronic obstructive pulmonary disease (COPD). In December 2010, he was found unresponsive on the floor with shortness of breath, incoherence, and incontinence. He was transported to the hospital where he subsequently died. His death certificate indicates that the immediate cause of death was cardiopulmonary arrest and that the underlying cause was end stage heart disease. The VA physician concluded that he concurred with the cause of death as shown on the death certificate. There was no clinical evidence that a triple arthrodesis in 1971 from which the Veteran recovered had any role whatsoever to play in causing his death or aggravating his significant underlying heart disease. It was not likely ("less likely than not") that the Veteran's service-connected left foot disability had any role to play in his demise. In August 2017, a second VA physician reviewed the Veteran's claims file and opined that it was not likely (not "as likely as not") that his service-connected arthrodesis of the left foot caused, or contributed substantially or materially to, his death (to the extent that it placed undue stress on his heart and contributed to the development of his fatal heart disease because it limited his ability to perform physical activities). The physician reasoned that the Veteran's activity was not limited, per his assessment, until 2005 when he developed lumbar spine stenosis. This was over 20 years after his first coronary event, which resulted in his requiring coronary artery stent placement in 1986. His heart problems preceded any decrease in activity. The physician further explained that the Veteran injured his left ankle in 1955 and 1971, underwent a triple arthrodesis in 1971 for a traumatic calcaneal bar of the left foot, and used orthotic shoes after the surgery. A review of the Veteran's treatment records since 1996 revealed that he reported good activity levels until he was found to have severe spinal stenosis at L2-3 and L3-4 in 2005. He underwent surgery for this disability and reported good activity levels for some time. Throughout the years he complained more of numbness than pain in his feet. He drank alcohol on a daily basis for an extended period of time and experienced an "idiopathic" peripheral neuropathy, most likely from his alcohol use. He never mentioned pain in his feet as limiting his activity. The physician then identified various instances in the Veteran's treatment records in support of this conclusion. For example, in 1999 he reported that he was very active working on a farm, in 2000 he reported that he experienced chest pain only with extreme exertion and that he was still active on his farm, in 2001 he denied any chest pain or shortness of breath and reported that he had "been working hard" and was "active physically," in 2003 he reported that he had lost weight and was active without chest pain, and in 2005 he reported that physical therapy had helped "tremendously," that he wanted to continue his chiropractic care, and that he did not want lower back surgery. In May 2006, the Veteran ran a roto-tiller in his garden and experienced no back pain, so he still wanted to wait on surgery. He underwent back surgery in July 2006 and thereafter reported to cardiology in August 2006 that he had been chopping wood, using a chain saw, and using his roto-tiller without chest pain. He was able to walk a mile with no chest pain in December 2006 (although he reported some chest pain with lifting logs). He reported occasional pain with "excessive activity" in April 2007, and reported in January 2008 that he could "walk without difficulty" and that his back pain did not disable him, but did "limit his activities." Moreover, in September 2009 the Veteran presented to cardiology and reported that he was fatigued. He had been taking unprescribed Lasix 40 mg twice a day and reported that despite his fatigue, he had "picked up a bushel of peas." His potassium was low and his prescriptions were adjusted to add a small amount of Lasix and potassium. In December 2010, he was found unresponsive at home and was admitted to the hospital in acute respiratory failure. At that time, his family was told of his dehydration and his (probably aspiration) pneumonia. His family requested palliative care only and specifically requested no surgery or antibiotics. He was given fluids for his electrolyte imbalance and dehydration, was placed into hospice, and died the next day. The physician further explained that the Veteran's cause of death was listed on his death certificate as cardiopulmonary arrest due to, or as a consequence of, end-stage heart disease. There were no other conditions listed as contributing to the Veteran's death. However, he had many other potentially lethal medical conditions, including a known 7 centimeter abdominal aortic aneurysm, known end stage chronic obstructive pulmonary disease, an altered mental status with an elevated white blood cell count (14,560) with 43 percent bands and heavy rhonchi on the right most consistent with aspiration pneumonia, and severe protein malnutrition and dehydration. These other potentially lethal conditions were in his emergency room record. Most death certificates list cardiopulmonary arrest as the cause of death because it is ultimately the last thing that goes awry. However, in this case, there was no autopsy. As a pathologist, the physician certainly would have listed infection/sepsis as a contributing cause of death. Almost half of the Veteran's white blood cells were bands, indicating a severe infection. In a dehydrated patient, a chest x-ray is not reliable, as there is not enough fluid in the patient for a pneumonia to be obvious. Even severely dehydrated, there were interstitial markings indicative of a possible acute interstitial infection. The Veteran ultimately died of cardiopulmonary arrest, but it was most likely precipitated by overwhelming sepsis. Lastly, the physician opined that the Veteran's fatal heart disease was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. She reasoned that there was no evidence in the Veteran's service treatment records that he had any symptoms or illnesses that could have resulted in his developing heart disease in 1986, 30 years after his separation from service. The Board finds that the May 2016 opinion is of minimal probative value because it is not accompanied by any specific rationale that explains why the Veteran's service-connected left foot disability did not contribute to his fatal cardiac disability. Also, the physician did not acknowledge or discuss the overall contention that the service-connected left foot disability placed undue stress on the Veteran's heart and contributed to the development of his heart disease because it limited his ability to perform physical activities. Rather, the physician gave a summary of the Veteran's medical history and provided a conclusory opinion that his service-connected left foot disability did not aggravate his underlying heart disease or otherwise contribute to his death. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). By contrast, the August 2017 opinions are based upon a complete review of the Veteran's medical records and reported history and are accompanied by specific rationales that are consistent with the evidence of record. Thus, the August 2017 opinions are entitled to substantial probative weight. Id; See also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (quoting Ardison v. Brown, 6 Vet.App. 405, 407 1994) (holding that a medical opinion "must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions." In addition to the medical evidence discussed above, the Board has considered the lay assertions of record, bur finds that they do not provide persuasive support for the claim. The appellant and her representative have expressed their belief that the Veteran's service-connected left foot disability contributed to his death. However, such assertions do not provide persuasive support for the claim. The appellant is certainly competent to describe matters within her personal knowledge, such as her observations of, and about, the Veteran. See, e.g., Charles v. Principi, 16 Vet. App. 370, 374 (2002); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (noting that lay evidence is competent with regard to facts perceived through the use of the five senses). Regardless, as laypersons not shown to have appropriate medical training and expertise, neither the appellant nor her representative is otherwise competent to render a probative opinion on a complex medical matter, such as whether there was a medical relationship between the Veteran's service-connected left foot disability and his death, as resolution of such question involves internal processes extending beyond an immediately observable cause-and-effect relationship. As the question of nexus in this case may not be competently addressed by lay evidence, the lay statements of record do not constitute competent, probative evidence on this point. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). See also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). There is no other medical or lay evidence indicating that the Veteran's fatal cardiac disability was related to service or that his service-connected left foot disability caused or contributed substantially or materially to cause his death, and neither the appellant nor her representative has alluded to the existence of any such evidence. Under these circumstances, the Board must conclude that the record does not support a finding that a disability of service origin caused or contributed substantially or materially to the Veteran's death. As such, service connection for the cause of the Veteran's death has not been demonstrated. The Veteran had admirable service and made sacrifices for his country. However, the competent, probative evidence weighs against a finding that there exists a medical nexus, or link, between the cause of his death and either that service or a service-connected disability. Hence, VA cannot grant service-connected burial benefits. In reaching the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the appellant's claim, the benefit-of-the-doubt doctrine is not applicable, and, hence, not helpful in this instance. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53- 56. ORDER The claim for service-connected burial benefits is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs