Citation Nr: 1802670 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 10-22 277 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for type II diabetes mellitus, to include as secondary to service-connected vestibular dysfunction with benign positional vertigo. 2. Entitlement to service connection for bilateral cataracts, to include as secondary to service-connected vestibular dysfunction with benign positional vertigo. 3. Entitlement to service connection for asthma, to include as secondary to service-connected vestibular dysfunction with benign positional vertigo. 4. Entitlement to service connection for left eye detached retina. 5. Entitlement to compensation under 38 U.S.C. § 1151 for right eye disability due to surgery of the right eye in 2008. 6. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. McPhaull, Counsel INTRODUCTION The Veteran served on active duty from April 1996 to April 1997. These matters come to the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, in August 2009 and February 2012. The August 2009 rating decision reopened a previously denied claim for depressive disorder and denied it on the merits; denied claims for service connection for type II diabetes mellitus, bilateral cataracts, and asthma; denied a claim for entitlement to a TDIU; and denied a claim of entitlement to compensation under 38 U.S.C. § 1151 for post-operative cataract of the right eye. The Board notes at this juncture that the August 2009 rating decision also denied entitlement to service connection for tinnitus, which the Veteran appealed. Service connection for tinnitus was subsequently granted in a September 2014 rating decision. Therefore, that issue is no longer before the Board for appellate review. The February 2012 rating decision denied entitlement to service connection for left eye detached retina. The Veteran and his wife presented testimony at a videoconference hearing before a Veterans Law Judge (VLJ) in May 2015. A transcript is of record. In November 2017 correspondence, the Board informed the Veteran that the VLJ before whom he had testified in May 2015 was no longer at the Board, and offered him the opportunity to have another Board hearing. In correspondence received later that month, the Veteran indicated that he did not wish to have another hearing. In August 2015, the Board reopened the claim for service connection for depressive disorder, and remanded the reopened claim as well as the other service connection claims for further development. A February 2017 rating decision granted service connection for depressive disorder. As such, this issue is no longer before the Board for appellate review. The Board observes that additional evidence has been received, however, the Veteran's representative has waived review of the evidence. See September 2017 Appellant's Brief. The issue of TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the agency of original jurisdiction (AOJ). VA will notify the Veteran if any action, on his part, is required. FINDINGS OF FACT 1. Diabetes mellitus did not have its onset during service, was not caused or aggravated by a service-connected disability, and it did not manifest within one year of service discharge. 2. Bilateral cataracts are not shown to have developed in service or as secondary to a service-connected disability. 3. Asthma is not related to service, and is not caused or aggravated by a service-connected disability. 4. A left eye detached retina did not have its onset during service and was not caused or aggravated by a service-connected disability. 5. Residuals from right eye cataract surgery were not proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault by VA or due to an event that was not reasonably foreseeable due to VA treatment provided in 2008. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for diabetes mellitus, to include as secondary to vestibular dysfunction with benign positional vertigo, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2017). 2. The criteria for an award of service connection for bilateral cataracts, to include as secondary to vestibular dysfunction with benign positional vertigo have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2017). 3. The criteria for an award of service connection for asthma, to include as secondary to vestibular dysfunction with benign positional vertigo have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2017). 4. The criteria for service connection for left eye detached retina have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2017). 5. The criteria for compensation under 38 U.S.C. § 1151 for residuals of a right eye cataract surgery provided by VA in 2008 are not met. 38 U.S.C. §§ 1151, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.361 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his 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 a duty to assist argument). Service connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as diabetes, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). The Board notes, however, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Disability which is proximately due to or the result of service-connected disease or injury shall be service-connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may be established by a showing that a nonservice-connected disability is caused or aggravated (chronically worsened) by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Diabetes mellitus The Veteran contends that he has diabetes mellitus due to his military service or as secondary to his service-connected vestibular dysfunction with benign positional vertigo. The service treatment records (STRs) are negative for any indication of diabetes mellitus. Laboratory testing conducted during active duty, including urinalysis, showed diabetes was not present. Post-service private, VA treatment records; as well as treatment records from the Social Security Administration show treatment for diabetes mellitus diagnosed in approximately 2008, ten years after service. During the May 2015 hearing, the Veteran testified that during service he was told he was diabetic and that the ketone level in his blood was going down. Pursuant to the Board August 2015 remand, VA obtained a medical opinion dated in January 2016. The claims file was reviewed in connection with the report. The examiner found that the Veteran's diabetes mellitus was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. The examiner noted that the referenced labs from April 1996 and April 1997 during active duty service document glucose levels of 83 and 94 with 1+ urine ketones. She noted that according to the American Diabetic Association and the World Health Organization, the diagnosis of diabetes requires a fasting blood glucose level of 126 or higher for confirmation. The examiner noted that neither of the lab values in service are within the range to support a diagnosis of diabetes at the time. She stated that mild ketonuria is often seen as a result of a fasting state during lab sampling and/or dietary changes. In the absence of any significant hyperglycemia, the ketonuria does not support or substantiate a diagnosis of diabetes during active duty service. The examiner noted the diagnosis of diabetes, based on the available medical records, was made in or around 2008, over ten years after separation from the military. She thus concluded that there is no evidence, therefore, to support that the development of type II diabetes mellitus was incurred in or caused by the Veteran's active duty service. Relative to the secondary service connection aspect of the claim, the examiner noted that vestibular dysfunction/BPPV is not included amongst the known risk factors (i.e., primary obesity, lifestyle, family history) for the development of type II diabetes mellitus. She further stated, that there is no medical data found in review of current medical literature that supports a pathophysiologic basis or mechanism for vestibular dysfunction/BPPV to cause or aggravate type II diabetes mellitus. Based on the foregoing, the Board finds that service connection for diabetes mellitus type II is not warranted in this case. The record indicates that the Veteran has a diagnosis of diabetes mellitus dating from approximately 2008. The service records do not indicate the presence of diabetes mellitus in service, nor is there any indication of diabetes mellitus within one year of active service. In addition, the examiner that has looked at the question has opined that the Veteran's diabetes mellitus was not due to service or caused or aggravated by his service-connected vestibular dysfunction with benign positional vertigo. There is no contrary opinion of record. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In this case, the VA examiner reviewed the Veteran's claims file and was apprised of the medical history and the Veteran's contentions regarding his claim. After examination and review, the examiner provided definite opinions supported by a reasoned rationale. As such, the opinions are highly probative. The Veteran has contended on his own behalf that his diabetes mellitus type II is related to service or casually related to his service-connected vestibular dysfunction with benign positional vertigo. In this regard, lay witnesses are competent to provide testimony or statements relating to symptoms or facts that are observable and within the realm of his or her personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir. 2007) (noting that lay testimony may be competent to identify a particular medical condition). Specifically, in Jandreau, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit commented that competence to establish a diagnosis of a condition can exist 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. Similarly, the United States Court of Appeals for Veterans Affairs (Court) has held 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. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In this case, however, the question of whether diabetes mellitus is related to military service or a service-connected disability is a complex medical question that is not subject to lay observation alone. Hence, the opinions of the Veteran in this regard are not competent in this case. Additionally, even though diabetes mellitus is a chronic disease and could serve as an independent basis for an award of service connection if proven, the lay evidence does not establish continuity of symptomatology here. Indeed, the evidence does not indicate the presence of diabetes mellitus until many years after service. As such, continuity of symptomatology from service is not shown in this case and cannot serve as a basis for service connection. In summary, the medical evidence in this case is against the claim. As such, the preponderance of the evidence is against service connection. Reasonable doubt does not arise and the claim, the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Bilateral cataracts and left eye retinal detachment The Veteran contends that he has eye disabilities due to his military service or as secondary to his service-connected vestibular dysfunction with benign positional vertigo. The STRs are negative for any indication of a chronic bilateral eye disability. Post-service treatment records show history of bilateral cataracts and retinal detachments. During the February 2016 VA examination, the examiner noted that the Veteran presented with poor vision of hand motion in the right eye and no light perception in the left eye. The examiner noted the history of retinal detachment in both eyes that have had surgical repair. She also noted that cataracts have been removed from both eyes. The examiner indicated that the etiology of retinal detachments were unknown and that records revealed cataract prior to removal were posterior subcapsular cataracts in both eyes that appeared sometime between November 2003 and September 2005. The examiner opined that it is not likely that the eye disorders had their onset during active service or are related to any in-service disease, event, or injury. She also noted that there is no evidence that the service-connected vestibular dysfunction with benign positional vertigo caused or aggravated the eye conditions. The examiner noted again that the etiology was unknown for the bilateral retinal detachments as they occurred in 2010 for the left eye, and 2013 for the right eye. She indicated that the Veteran reported that during service he was injured when water/chemicals got into his eyes. She noted that the Veteran was given drops and that his eyes recovered within a few weeks' time. The examiner noted that the injury and history of conjunctivitis in December 1996 would not affect the retina or the lenses in the eyes. Based on the forgoing, entitlement to service connection for bilateral cataracts, and left eye retinal detachment is not warranted. The evidence does indicate that the Veteran has diagnoses related to his claims for bilateral cataracts and left eye retinal detachment. The February 2016 VA examiner who reviewed the claims file and examined him, found that these conditions were not related to the service or his service-connected vestibular dysfunction with benign positional vertigo. There are no contrary opinions of record. As already discussed above, in determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this case, the February 2016 examiner reviewed the claims file and was apprised of the medical history and the Veteran's contentions regarding his eye claims. After examination and review, the examiner provided definite opinions supported by rationale and the evidence. As such, the opinions are highly probative. The Veteran has contended on his own behalf that his claimed disabilities are related to his military service or service-connected vestibular dysfunction with benign positional vertigo. In this regard, as noted, lay witnesses are competent to provide testimony or statements relating to symptoms or facts that are observable and within the realm of his or her personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir. 2007). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In this case, however, the questions relating to whether the claimed eye disabilities are related to military service are complex medical questions relating to internal medical processes that extend beyond an immediately observable cause-and-effect relationships of the type that the courts have found to be beyond the competence of lay witnesses. Jandreau, 492 F.3d at 1377, n.4. Hence, the opinions of the Veteran in this regard are not competent in this case. For the foregoing reasons, the preponderance of the evidence is against the eye disability claims. The benefit of the doubt doctrine is therefore not for application and the claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Asthma The Veteran seeks entitlement to service connection for asthma as a result of his military service, or, in the alternative, as secondary to his service-connected vestibular dysfunction with benign positional vertigo. The STRs do not reflect any treatment or symptomatology referable to asthma. Post-service treatment records show history of treatment for respiratory disorder claimed as asthma as early as 2003. During the March 2016 VA examination, the examiner noted the Veteran's history of asthma. In a subsequent November 2016 opinion, the examiner found that the asthma was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner reasoned that the Veteran's enlistment and separation examination findings from March 1996 and April 1997, respectively are negative for a diagnosis of asthma or chronic respiratory conditions. It was noted that his shortness of breath and intermittent wheezing date back to 2003 by available treatment records, several years after his discharge from active duty. The examiner noted that a diagnosis of asthma was made in 2005 by a VA pulmonologist based solely on the history provided by the Veteran at the time. She noted there is no evidence to support a diagnosis of, or onset of, asthma either during or in the year following the Veteran's active duty service. And, assertions by the Veteran that he was exposed to chemicals from the distillation plant that resulted in shortness of breath and asthma are not substantiated by the evidence. The examiner indicated that although chemical/occupational exposures may contribute to the development of airway hyperresponsiveness and/or inflammation consistent with asthma, this type of reaction typically develops in proximity to the exposure and resolves in the absence of repeat exposures. She noted that STRs are negative for evaluation or treatment for a recurring respiratory condition that could have been consistent with hypersensitivity to the claimed exposure. There is furthermore, no confirmation of the claimed exposure in STRs, nor have there been diagnostic pulmonary function testing (PFT) test results to date (despite multiple attempts) confirming the presence of a reversible airway obstruction consistent with asthma or hyperresponsive airways. The examiner noted that several nondiagnostic PFTs due to poor effort are of record and the most recent attempt at PFT testing in April 2016 notes "Pt is not able to perform PFT due to shortness of breath." Medical treatment notes consistently notate "asthma stable" with no active respiratory complaints in over a year. Neither the claimed exposure nor the actual medical condition have been validated by STRs or medical treatment records to substantiate a claim for asthma secondary to any in-service events or exposures. Furthermore, the examiner indicated that for the Veteran to have persistent shortness of breath at this time in the absence of repeat exposure to the chemicals from the distillation plant during his one year of active duty service almost twenty years ago strongly suggests that his asthma is unrelated to his claimed in-service exposure. In a January 2017 addendum opinion, the examiner indicated that the Veteran's poorly defined respiratory condition (referred to as asthma) is a separate and unrelated issue from his service connected vestibular dysfunction with benign positional vertigo (BPPV). She noted that the pathophysiology behind BPPV as an inner ear/neurological dysfunction has not been demonstrated in medical literature or clinical practice/reports to have any causal or augmental association with asthma or the claimed respiratory condition in this case. Based on the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for asthma. In this regard, the Board places great probative weight on the November 2016 and January 2017 VA examiner's opinions that the Veteran's asthma was not related to his active service or service-connected vestibular dysfunction with benign positional vertigo. The Board observes that the VA examiner considered the Veteran's record and medical history in rendering the opinions. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Ardison v. Brown, 6 Vet. App. 405, 407 (1994). The examiner clearly reviewed the claims file and summarized pertinent clinical records, so she was fully aware of the extent of the Veteran's claimed disorder. Additionally, she provided an etiological opinion, complete with the rationale described above. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl, supra. Consequently, the Board assigns great probative value to the VA examiner's opinions. With specific regard to the secondary service connection aspect of the claim, the January 2017 opinion clearly indicates that asthma was not caused or aggravated by his service-connected vestibular dysfunction with benign positional vertigo and provided a sufficient rationale for such opinion based on review of medical literature. As discussed above, the Board finds the opinion to be sufficient for appellate review and of high probative value. The Veteran has contended on his own behalf that his asthma is related to his military service or service-connected vestibular dysfunction with benign positional vertigo. In this regard, again, as noted, lay witnesses are competent to provide testimony or statements relating to symptoms or facts that are observable and within the realm of his or her personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir. 2007). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In this case, however, the questions relating to whether the respiratory disability is related to military service are complex medical questions relating to internal medical processes that extend beyond an immediately observable cause-and-effect relationships of the type that the courts have found to be beyond the competence of lay witnesses. Jandreau, 492 F.3d at 1377, n.4. Hence, the opinions of the Veteran in this regard are not competent in this case. For the foregoing reasons, the preponderance of the evidence is against the asthma claim. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1151 eligibility - right eye The Veteran also seeks entitlement to compensation under 38 U.S.C.A. § 1151 for post-operative cataract of the right eye. VA treatment records document that he underwent right eye phacoemulsification/intraocular lens implant (phaco/IOL) due to diagnosis of right eye cataract on June 17, 2008, and Yttrium Aluminum Garnet (YAG) laser capsulotomy on the right eye on August 20, 2008. The Board observes that this issue was remanded, in part, in order for the RO to obtain the signed informed consent. The August 2008 informed consent was associated with the claims file in September 2016. In a March 2013 opinion, the examiner noted that the Veteran underwent an uncomplicated phacoemulsification removal of a cataract of the right eye and was implanted with an intraocular lens implant. She noted that postoperative refraction was noted to be spherical equivalence of -2.75 diopters which was unexpected. The examiner noted that within 1 month it was noted and various treatment options including lens exchange was discussed with the Veteran. The examiner noted that although less common now than in the past due to improvement of instrumentation, an incorrect lens power is always a possibility either because the lens implant is mismarked or calculation are incorrect. The examiner noted that the Veteran is myopic (nearsighted). She indicated that the post-operative myopia does not appear to be secondary to carelessness, negligence of lack of skill, or similar incidence of fault on the part of the attending VA personnel. She noted that myopia resulted from an event that could not have reasonable been foreseen by a reasonable healthcare provider and was recognized soon after surgery. In a January 2017 VA addendum medical opinion, the examiner noted that after the Veteran's right eye surgery a "myopic refractive error was found." The optometrist indicated that a patient may need glasses after cataract surgery is a known risk of cataract surgery, and is not indicative of carelessness, negligence, or lack of proper skill which constitutes fault on the part of the VA. Title 38, United States Code § 1151 provides compensation in situations in which a claimant suffers an injury or an aggravation of an injury resulting in additional disability or death by reason of VA hospitalization, or medical or surgical treatment, and the proximate cause of the additional disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing the medical or surgical treatment, or the proximate cause of additional disability or death was an event which was not reasonably foreseeable. To determine whether a Veteran has an additional disability, VA compares the Veteran's condition immediately before the beginning of the medical treatment upon which the claim is based to his or her condition after such treatment has stopped. 38 C.F.R. § 3.361(b). To establish that VA treatment caused additional disability, the evidence must show that the medical treatment resulted in the additional disability. Merely showing that a Veteran received treatment and that the Veteran has an additional disability, however, does not establish cause. 38 C.F.R. § 3.361(c)(1). The proximate cause of disability is the action or event that directly caused the disability, as distinguished from a remote contributing cause. To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing medical treatment proximately caused a Veteran's additional disability, it must be shown that the medical treatment caused the Veteran's additional disability; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the Veteran's or, in appropriate cases, the Veteran's representative's informed consent. 38 C.F.R. § 3.361(d), (d)(1). Whether the proximate cause of a Veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32 of this chapter. Schertz v. Shinseki, 26 Vet. App. 362 (2013); 38 C.F.R. § 3.361(d)(2). The March 2013 and January 2017 opinions are not contradicted by any other medical opinion, and the undersigned finds these opinions to be definitive as to the matter of whether the Veteran developed additional disability of residuals of a cataract removal of the right eye due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault by VA or due to an event that was not reasonably foreseeable as a result of the VA medical treatment provided in 2008. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Although these opinions do not explicitly discuss what a reasonable health care provider would have disclosed; the physician who provided the VA opinion and the health care providers who prepared the informed consent form believed that loss in vision was a foreseeable consequence of the cataract surgery. There is no basis for finding that the health care providers or the VA physician providing the opinion were unreasonable. The Board has considered the arguments presented on behalf of the Veteran at the hearing as to why he believes that the benefits pursuant to 38 U.S.C. § 1151 are warranted. These arguments, however are less probative, than the opinions of the VA physician who evidenced the training and expertise to opine as to the proper standard of care and foreseeable consequences of the Veteran's surgery. There is no indication that the Veteran has the requisite training or knowledge to offer such an opinion. See Boehlert v. Nicholson, 21 Vet. App. 456 (2007). Rendering an opinion as to whether an individual sustained additional disability that was proximately caused by improper treatment, or lack of treatment, requires an understanding of a complex medical and physical process, which is beyond the known expertise of the Veteran. Therefore, as he is not competent to render an opinion as to whether he developed additional disabilities of a right eye disorder, post-cataract surgery caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault by VA or due to an event that was not reasonably foreseeable, any assertions in this regard have no probative value, and the Veteran cannot support the claim, nor counter the negative medical opinion, on the basis of lay assertions alone. In short, the preponderance of the evidence is against this claim on appeal. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. As the preponderance, however, of the evidence is against the claim, that doctrine is not applicable in the instant appeal, and the claim for compensation under 38 U.S.C. § 1151 for residuals of a right eye cataract removal, must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for type II diabetes mellitus, to include as secondary to service-connected vestibular dysfunction with benign positional vertigo is denied. Service connection for bilateral cataracts, to include as secondary to service-connected vestibular dysfunction with benign positional vertigo is denied. Service connection for asthma, to include as secondary to service-connected vestibular dysfunction with benign positional vertigo is denied. Service connection for left eye detached retina is denied. Entitlement to compensation under 38 U.S.C. § 1151 for right eye disability due to surgery of the right eye in 2008 is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's TDIU claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). With regard to the TDIU issue, the Veteran is currently service connected for bilateral hearing loss, evaluated as 60 percent; depressive disorder, evaluated as 50 percent; vestibular dysfunction with benign positional vertigo, evaluated as 30 percent; and tinnitus, evaluated as 10 percent. A combined disability evaluation of 90 percent is in effect. Thus, the Veteran currently meets the threshold criteria for entitlement to TDIU under 38 C.F.R. § 4.16. Furthermore, some post-service treatment records indicate that the Veteran's service-connected disabilities are factors that have contributed to his inability to attain and sustain gainful employment. The Board finds that further medical guidance is needed before this claim can be adequately adjudicated. Indeed, it is unclear from the record whether the Veteran's service-connected disabilities alone; or, whether the non-service connected conditions related to his eye disabilities contribute to his ability to obtain and maintain gainful employment. The Board notes that the ultimate question of whether a Veteran is capable of substantial gainful employment is not a medical one; rather, that determination is for the adjudicator. 38 C.F.R. § 4.16(a); Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). The Board notes, however, medical examiners are responsible for providing a full description of the effects of disability upon the person's ordinary activity. 38 C.F.R. § 4.10; Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). As the record is unclear, the Board requires a medical examination for a full description of the effects of the Veteran's service-connected disabilities upon his employment and ordinary activities. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran an appropriate VA examination(s) for a full description of the functional effects of his service-connected disabilities upon his employment and ordinary activities. The examiner is advised that the Veteran is service-connected for the following disabilities: bilateral hearing loss, depression, vestibular dysfunction with benign positional vertigo, and tinnitus. The examiner is requested to describe the Veteran's employment and educational history. Thereafter, the examiner should assess the functional impairment caused by the Veteran's service-connected disabilities in the aggregate (i.e., jointly), on his ordinary activities, to include his employability, taking into consideration his level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. A complete rationale should be provided for all opinions offered. 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the claim should be readjudicated based on the entirety of the evidence. If the benefit sought on appeal remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ H.M. WALKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs