Citation Nr: 1802383 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 16-35 872 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim for service connection for posttraumatic stress disorder (PTSD) for substitution purposes. 2. Whether new and material evidence has been received to reopen a previously denied claim for service connection for bilateral hearing loss for substitution purposes. 3. Whether new and material evidence has been received to reopen a previously denied claim for service connection for hypertension for substitution purposes. 4. Entitlement to service connection for bilateral hearing loss for substitution purposes. 5. Entitlement to service connection for hypertension for substitution purposes. 6. Entitlement to service connection for pulmonary fibrosis for substitution purposes. REPRESENTATION Appellant represented by: Jeany Mark, Attorney at Law ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran served on active duty from August 1963 to February 1964, from August 1990 to September 1990 and from September 2001 to January 2004. He died in November 2014. The appellant is the Veteran's surviving spouse. In December 2014, the appellant submitted a VA 21-0847 request to be substituted as the appellant. In a June 2016 administrative decision, the RO determined that the appellant meets the basic eligibility for substitution in this appeal. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a January 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Since the issuance of the June 2016 statement of the case, additional evidence has been added to the Veteran's claims file. The representative has waived consideration of this evidence by the AOJ. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. In an October 2008 rating decision, the RO denied service connection for PTSD, bilateral hearing loss and hypertension. The Veteran did not timely perfect an appeal of these determinations. 2. Evidence received since the October 2008 rating decision does not raise a reasonable possibility of substantiating the claim of service connection for PTSD for substitution purposes.. 3. Evidence received since the October 2008 rating decision includes evidence that is not cumulative or redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim for service connection for bilateral hearing loss for substitution purposes.. 4. Evidence received since the October 2008 rating decision includes evidence that is not cumulative or redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim for service connection for hypertension for substitution purposes. 5. Resolving reasonable doubt in the Veteran's favor, bilateral hearing loss incurred in service. 6. Resolving reasonable doubt in the Veteran's favor, hypertension incurred in service. 7. Resolving reasonable doubt in the Veteran's favor, pulmonary fibrosis incurred in service. CONCLUSIONS OF LAW 1. The October 2008 rating decision is final. 38 U.S.C. § 7105 (West 2012); 38 C.F.R. § 20.1103 (2007). 2. New and material evidence to reopen a claim of entitlement to service connection for PTSD for substitution purposes has not been received, and the claim is not reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (2017). 3. New and material evidence has been received since February 2008, and the claim of entitlement to service connection for bilateral hearing loss is reopened for substitution purposes. 38 U.S.C. § 7105, 5121, 5121A (2012); 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2017). 4. New and material evidence has been received since February 2008, and the claim of entitlement to service connection for hypertension is reopened for substitution purposes. 38 U.S.C. § 7105, 5121, 5121A (2012); 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2017). 5. Service connection for bilateral hearing loss is established for substitution purposes. 38 U.S.C. §§ 1110, 5107, 5121 (2012); 38 C.F.R. § 3.303, 3.304, 3.307, 3.309, 3.1000 (2017). 6. Service connection for hypertension is established for substitution purposes. 38 U.S.C. §§ 1110, 5107, 5121 (2012); 38 C.F.R. § 3.303, 3.304, 3.307, 3.309, 3.310, 3.1000 (2017). 7. Service connection for pulmonary fibrosis is established for substitution purposes. 38 U.S.C. §§ 1110, 5107, 5121 (2012); 38 C.F.R. § 3.303, 3.304, 3.307, 3.309, 3.1000 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). VA's duty to notify was satisfied by an October 2013 letter. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Neither the appellant nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Laws and Regulations Initially, the Board notes that the issues before the Board here have been recharacterized as for substitution purposes.. Although it may appear that, because the appellant's claims are now before the Board, it does not make a difference whether they are adjudicated as accrued benefits claims or as requests for substitution. There is, however, a significant difference. When adjudicating the former, only the evidence of record at the time of the Veteran's death may be considered as the basis for a determination on the merits of a claim. By contrast, when a properly qualified substitute claimant "continues the pending claim in the footsteps of the veteran" after his or her death, additional development of the record may be undertaken if that is deemed appropriate and/or necessary in order to adequately adjudicate the merits of the claim. Unlike accrued benefits claims, the record is not closed on the date of death of the original claimant, but rather, remains open for the submission and development of any pertinent, additional evidence. Thus, it is to the appellant's advantage to have her claims adjudicated as a substitute claimant pursuant to 38 U.S.C. § 5121A, rather than as they were originally adjudicated. In other words, because the appellant is a substitute claimant in this case, the Board will consider all evidence submitted in this case, to include evidence submitted both prior to and after the Veteran's death. I. Claims to Reopen The Veteran filed claim for service connection for PTSD, bilateral hearing loss and hypertension disabilities which were denied in an October 2008 rating decision. The denial of the Veteran's PTSD claim was on the basis that the evidence failed to show a current diagnosis of PTSD. The denial of the Veteran's bilateral hearing loss and hypertension disabilities were on the basis that the evidence failed to show that the Veteran's bilateral hearing loss and hypertension disabilities were related to his service. The Veteran was notified of this decision but did not appeal. As the Veteran did not appeal the October 2008 rating decision, that decision is now final based on the evidence then of record. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. The Veteran sought to reopen his claims for service connection for PTSD, bilateral hearing loss and hypertension disabilities in November 2012. VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). See also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). 38 C.F.R. § 3.156(a) defines "new" evidence as evidence not previously submitted to agency decision makers and "material" evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2017). In determining whether new and material evidence has been received, VA must initially decide whether evidence received since the prior final denial is, in fact, new. As indicated by the regulation cited above, and by judicial case law, "new" evidence is that which was not of record at the time of the last final disallowance (on any basis) of the claim, and is not duplicative or "merely cumulative" of other evidence then of record. This analysis is undertaken by comparing the newly received evidence with the evidence previously of record. After evidence is determined to be new, the next question is whether it is material. The provisions of 38 U.S.C. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-3 (1996). Here, the last final denial of the claims is the October 2008 rating decision. Furthermore, for purposes of the "new and material" analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). A. PTSD As noted above, the October 2008 rating decision denied service connection for PTSD on the basis that the evidence did not show a confirmed diagnosis of PTSD. Evidence received since the October 2008 rating decision includes VA treatment records and a November 2013 VA examination for PTSD. However, the VA treatment records noted negative PTSD screens while the November 2013 VA examiner specifically determined that the Veteran did not meet the criteria for a mental disorder to include PTSD. The Board finds that the evidence received since the October 2008 rating decision is new as it was not of record at the time of the prior denial, but the newly submitted evidence is not material as it is cumulative and redundant in nature of the record in October 2008. To the extent that the evidence relates to the reason the claim was previously denied, the new evidence does not raise a reasonable possibility of substantiating the claim for service connection for PTSD. Significantly, competent evidence of a PTSD disability or a link of a PTSD disability to the Veteran's service has not been added to the record. Overall, there is no competent evidence or opinion suggesting that the Veteran had a PTSD disability or that any PTSD disability was in any way related to his service. Here, where the claim turns on a medical matter, unsupported lay statements, even if new, cannot serve as a predicate to reopen a previously disallowed claim. See Moray v. Brown, 5 Vet. App. 211, 214 (1993). Thus, the Veteran and appellant's new statements submitted since the October 2008 rating decision are insufficient to reopen the claim. The appellant's request to reopen the previously disallowed claim of entitlement to service connection for PTSD for substitution purposes is denied because none of the newly submitted evidence pertains to the reasons for the prior denial nor raises the reasonable possibility of substantiating the appellant's underlying claim. See 38 C.F.R. § 3.156(a) (2017). As the appellant has not fulfilled the threshold burden of submitting new and material evidence to reopen the finally disallowed claim of service connection for PTSD for substitution purposes, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). In sum, absent any new and material evidence of a PTSD disability that is due to service, the claim for service connection for PTSD for substitution purposes cannot be reopened. See 38 C.F.R. § 3.156(a) (2017). B. Bilateral Hearing Loss Evidence received since the October 2008 rating decision includes an October 2017 correspondence from a private physician who opined that it was more likely than not that the Veteran developed hearing loss that was secondary to noise exposure in service. The prior denial of service connection for a bilateral hearing loss disability was based on a lack of evidence that there was a relationship between the Veteran's bilateral hearing loss and his service. The private physician's October 2017 correspondence indicated that the Veteran's bilateral hearing loss disability was a result of his in-service noise exposure. Hence, this evidence raises a reasonable possibility of substantiating the appellant's claim for service connection for bilateral hearing loss for substitution purposes. As noted above, for purposes of determining whether the claim should be reopened, the evidence is presumed to be credible. Under these circumstances, the Board concludes that the criteria for reopening the claim for service connection for a bilateral hearing loss disability for substitution purposes have been met. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156. C. Hypertension Evidence received since the October 2008 rating decision includes an October 2017 correspondence from a private physician who opined that it was more likely than not that the Veteran's hypertension developed in service. The prior denial of service connection for a hypertension disability was based on a lack of evidence that there was a relationship between the Veteran's hypertension and his service. The private physician's October 2017 correspondence indicated that the Veteran's hypertension developed in service. Hence, this evidence raises a reasonable possibility of substantiating the appellant's claim for service connection for hypertension for substitution purposes. As noted above, for purposes of determining whether the claim should be reopened, the evidence is presumed to be credible. Under these circumstances, the Board concludes that the criteria for reopening the claim for service connection for a hypertension disability for substitution purposes have been met. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156. II. Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include bilateral hearing loss and hypertension may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as hypertension is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service- connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice- connected disability by a service- connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The provisions of 38 U.S.C. § 1111 provide that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). A pre-existing injury or disease noted at entry will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. The provisions of 38 C.F.R. § 3.306(b) provide that aggravation may not be conceded unless the pre-existing condition increased in severity during service. An important distinction between section 1111's aggravation prong of the presumption of soundness and section 1153 presumption of aggravation is the burden of proof. Under section 1111, the burden is on the Government to show by clear and unmistakable evidence that there was no increase in disability in service or, that any increase was due to the natural progress of the disease. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Under section 1153, however, the Appellant bears the burden of showing that his preexisting condition worsened in service. Once the veteran establishes worsening, the burden shifts to the Secretary to show by clear and unmistakable evidence that the worsening of the condition was due to the natural progress of the disease. Horn v. Shinseki, 25 Vet. App. 231, 235 (2014). A pre-existing injury or disease will be considered to have been aggravated by active military, naval or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). A. Bilateral Hearing Loss For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Tests are less than 94 percent. 38 C.F.R. § 3.385. Additionally, it is noted that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Veteran had an audiological evaluation in December 1967, at which time auditory thresholds were recorded. However, because it is unclear whether such thresholds were recorded using American Standards Association (ASA) units or International Standards Organization-American National Standards Institute (ISO-ANSI) units, the Board will consider the recorded metrics under both standards, relying on the unit measurements most favorable to the Veteran's appeal. As it relates to VA examinations and VA records, audiological reports were routinely converted from ISO-ANSI results to ASA units until the end of 1975 because the regulatory standard for evaluating hearing loss was not changed to require ISO-ANSI units until September 9, 1975. In light of the above, and where necessary to facilitate data comparison for VA purposes in the decision below, including under 38 C.F.R. § 3.385, audiometric data originally recorded using ASA standards will be converted to ISO-ANSI standard by adding between 5 and 15 decibels to the recorded data. The converted audiometric data are in parentheses. Audiometric testing on a December 1967 examination revealed pure tone thresholds, obtained by air conduction, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5(20) 5(15) 0(10) 0(10) 10(15) LEFT 5(20) 5(15) 0(10) 5(55) 10(15) Audiometric testing in November 1979 revealed pure tone thresholds in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 5 25 55 LEFT 5 5 5 40 45 Audiometric testing in November 1990 revealed pure tone thresholds in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 5 25 55 LEFT 5 0 10 50 70 Audiometric testing in April 2000 revealed pure tone thresholds in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 10 40 75 LEFT 5 5 10 65 75 The Veteran underwent a VA examination in September 2008. The examiner noted that while the Veteran's hearing was normal on his separation examination in 1967, high frequency hearing loss began in the 1970's. The examiner also noted that there was a significant threshold shift between the 2000 audiometric results and the 2008 audiometric results. A 2000 audiogram also indicated an increase in hearing loss from a previous examination in 1990. The examiner noted that the increase seen on examination today compared to the results from the 2000 examination was significantly greater than that seen from 1990 to 2000. The examiner opined that based on this increase of hearing loss over the last 8 years, and given that the nature of the Veteran's reported duties and experiences in service, it could be stated that his pre-existing hearing loss was at least as likely as not aggravated beyond a normal rate of progression by noise exposure in active duty. Audiometric testing in September 2008 revealed pure tone thresholds in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 35 50 90 LEFT 25 30 40 80 90 Speech audiometry revealed speech recognition ability of 92 percent in the right ear and of 88 percent in the left ear. In an October 2017 letter, a private physician opined that it was more likely than not that the Veteran developed hearing loss secondary to his noise exposure while in service. The examiner noted that on a 1967 hearing evaluation the Veteran's hearing was normal while a 1979 audiogram demonstrated hearing deterioration at multiple frequencies. After resolving all reasonable doubt in favor of the appellant, the Board finds service connection for bilateral hearing loss for substitution purposes is warranted. The record shows that the Veteran had bilateral hearing loss for VA compensation purposes. As a result, the first element of medical evidence of a current disability is accordingly met. Therefore, the question to be decided in the present appeal is whether the bilateral hearing loss was associated with the Veteran's active duty. The evidence demonstrates that military noise exposure is conceded as he had military noise exposure as he reported exposure to small arms fire, heavy artillery, grenades, helicopters, aircraft engines and tanks. Thus, his assertions of in-service noise exposure appear to be credible, and consistent with the circumstances of service. The Veteran was also competent to report in-service exposure to noise. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet App 370 (2002). For all of these reasons, such exposure is presumed. 38 U.S.C. § 1154(a) (b) (2012). As noted above, in an October 2017 opinion, a private physician concluded that the Veteran developed hearing loss secondary to his noise exposure while in service. Additionally, the September 2008 VA examiner also opined that the Veteran's pre-existing hearing loss was at least as likely as not aggravated beyond a normal rate of progression by noise exposure during one of the Veteran's later periods of active duty. There is also is no contrary medical evidence of record that indicates that the Veteran's hearing loss was not related to his service or that his hearing loss was not aggravated beyond a normal rate of progression by a subsequent period of service. As a result, the Board finds that service connection is warranted for bilateral hearing for substitution purposes. In sum, for the reasons and bases discussed above, all doubt is resolved in favor of the appellant, and service connection for a bilateral hearing loss disability for substitution purposes is warranted. See 38 U.S.C. § 5107(b). B. Hypertension Factual Background and Analysis Notably, for hypertension, regulations provide that hypertension for VA purposes means that the diastolic blood pressure is predominantly 90 or more or systolic blood pressure is predominantly 160 or more. Hypertension must be confirmed by readings taken two or more times on three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). A December 1969 service treatment record noted a blood pressure reading of 116/80. A November 1979 service treatment record noted a blood pressure reading of 122/72. An April 200 service treatment record noted blood pressure readings of 180/112, 180/108 and 184/102. In an October 2017 letter, a private physician opined that it was more likely than not that the Veteran's hypertension developed in service. The physician noted that the Veteran's blood pressure readings were normal in 1967 while in 1979 and 1983 he was noted to have blood pressure readings consistent with pre-hypertension. The physician also noted that the Veteran's pulmonary hypertension developed secondary to his pulmonary fibrosis as pulmonary hypertension was a known complication of pulmonary fibrosis. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for hypertension for substitution purposes is warranted. Initially, the Board notes that the Veteran had a diagnosis of hypertension. Accordingly, the first element of service connection is satisfied. Notably, in an October 2017 letter, the private physician opined that it was more likely than not that the Veteran's hypertension developed in service as the Veteran's blood pressure readings were normal in 1967 while in 1979 and 1983 he was noted to have blood pressure readings consistent with pre-hypertension. While the Board notes that this rationale does not necessarily provide adequate rationale for a finding that the Veteran's hypertension was a direct result of the Veteran's service, the Board finds that service connection for substitution purposes is warranted on a secondary basis as the record contains medical evidence that the Veteran's hypertension disability was related to his now service-connected pulmonary fibrosis disability (which will be addressed below). Notably, the private physician in an October 2017 letter noted that the Veteran's pulmonary hypertension developed secondary to his pulmonary fibrosis. The physician also indicated that pulmonary hypertension was a known complication of pulmonary fibrosis. Significantly, there is no contrary medical evidence of record that indicates that the Veteran's hypertension disability was not caused or aggravated by treatment for his now service-connected pulmonary fibrosis disability. As a result, the Board finds that service connection for substitution purposes is warranted on a secondary basis. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for a hypertension disability for substitution purposes is granted. See 38 U.S.C.A. § 5107(b). C. Pulmonary Fibrosis As a threshold matter, the Board notes that military records reflect that the Veteran had active military service in the Southwest Asia Theater of Operations during the Persian Gulf War. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. The law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service, discussed below, thus are applicable in this case. Under 38 C.F.R. § 3.317, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. See 38 C.F.R. § 3.317(a)(1) (2017). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. The Veteran underwent a VA examination in October 2013. The examiner noted that the Veteran was diagnosed with pulmonary fibrosis in 2012. The examiner opined that the Veteran's pulmonary fibrosis was a clear and specific etiology and diagnosis. The examiner noted that pulmonary fibrosis scars and thickens the tissue around and between the air sacs in the lungs and that the damage could be caused by many things, such as airborne toxins (bird droppings) much like the Veteran was exposed to in Southwest Asia. In an October 2017 letter, a private physician opined that it was more likely than not that the Veteran's pulmonary fibrosis was secondary to his exposure to toxins while in service. The physician noted that the Veteran had active military service in the Persian Gulf that exposed him to environmental hazards such as smoke from burn pits, oil-well fires and other pollutants. As noted in literature provided by the physician, pulmonary fibrosis can develop secondary to environmental exposure. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for pulmonary fibrosis for substitution purposes is warranted. As noted above, as the Veteran had active military service in the Southwest Asia Theater of Operations, the law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service, discussed above, thus are applicable in this case. In this regard, the Board first observes that the Veteran's pulmonary fibrosis was not related to an undiagnosed illness, as the disorder does, in fact, carry a diagnosis. . The diagnosed pulmonary fibrosis is attributable to a specific cause, and not an undiagnosed illness or medically unexplained chronic multi symptom illnesses. Thus, while the Veteran served in Southwest Asia, the Veteran did not have multisymptom medically undiagnosed illness as the October 2013 VA examiner specifically determined that the Veteran's pulmonary fibrosis had a clear and specific etiology and diagnosis. As the disorder of pulmonary fibrosis had been diagnosed, the Board concludes that the special provisions pertaining to undiagnosed illnesses are not applicable, and service connection for pulmonary fibrosis cannot be granted under the presumptive provisions of 38 U.S.C. §1117 and 38 C.F.R. § 3.317. However, in cases where a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. §§ 1110 and 1131 are warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). The Veteran's medical record shows that he had been diagnosed with pulmonary fibrosis. Accordingly, as there was a current diagnosis of pulmonary fibrosis, the first element of service connection is satisfied. As noted above, in an October 2017 opinion, a private physician opined that it was more likely than not that the Veteran's pulmonary fibrosis was secondary to his exposure to toxins while in service. Additionally, the October 2013 VA examiner also noted that pulmonary fibrosis could be caused by many things, such as airborne toxins (bird droppings) much like the Veteran was exposed to in Southwest Asia. There is also is no contrary medical evidence of record that indicates that the Veteran's pulmonary fibrosis was not related to his service. As a result, the Board finds that service connection is warranted for pulmonary fibrosis for substitution purposes. In sum, for the reasons and bases discussed above, all doubt is resolved in favor of the appellant, and service connection for a pulmonary fibrosis disability for substitution purposes is warranted. See 38 U.S.C. § 5107(b). ORDER As new and material evidence has not been received, reopening of the claim for service connection for PTSD for substitution purposes is denied. New and material evidence has been received to reopen the claim of entitlement to service connection for bilateral hearing loss for substitution purposes. New and material evidence has been received to reopen the claim of entitlement to service connection for hypertension for substitution purposes. Entitlement to service connection for bilateral hearing loss for substitution purposes is granted. Entitlement to service connection for hypertension for substitution benefits purposes is granted. Entitlement to service connection for pulmonary fibrosis for substitution purposes is granted. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs