Citation Nr: 18155639 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 17-34 957 DATE: December 4, 2018 ORDER Service connection for an umbilical hernia (claimed as right side abdominal pain) is denied. REMANDED Entitlement to service connection to a cesarean section (C-section) scar is remanded. FINDING OF FACT The Veteran’s umbilical hernia did not have onset in service, to include as due to the in-service C-section procedure, and is not otherwise related to service. CONCLUSION OF LAW The criteria for service connection for an umbilical hernia have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 2004 to September 2008, with additional Reserve service. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Additional evidence was added to the file following the statement of the case issued in April 2017. However, the evidence is either not relevant and/or essentially duplicative of evidence that had been previously submitted and considered by the Agency of Original Jurisdiction (AOJ); therefore, a waiver is not necessary. See 38 C.F.R. 20.1304. 1. Entitlement to service connection for an umbilical hernia. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). The Veteran seeks service connection for an umbilical hernia as due to an emergency C-section procedure performed during service. See August 2015 notice of disagreement; see also August 2017 VA Form 9. The Veteran has a current diagnosis of an umbilical hernia, thereby meeting the first element of service connection. See March 2015 VA contract examination. The Veteran has also met the second element of service connection as the service treatment records show she underwent an emergency C-section in July 2008. However, the Board finds that service connection is not warranted, as the third element, a causal relationship, has not been shown. The first indication of abdominal pain related to the C-section was in September 2008, a week after separation from service. The treatment record showed that the Veteran complained of surgical site tenderness, but the abdomen was normal upon examination. A March 2013 Reserves Health record reflected no abdomen-related health concerns. Subsequent Reserve and treatment records showed that the Veteran reported pain with sit-ups and sought surgical consultations. In June 2013, the Veteran was seen for complaints of a ventral hernia. Subsequently, the Veteran was diagnosed by a computed tomography (CT) scan in July 2013, for anterior abdominal wall laxity and a small fat-filled umbilical hernia. The Veteran was afforded an initial VA contract examination in March 2015. She reported having pain around her “belly-button.” No further treatment was noted for the condition. The examiner reviewed the service treatment records and noted that the Veteran did not report a persistent condition during service. The examiner also noted that she stated the hernia was diagnosed after she left active service. Thus, the examiner opined that the umbilical hernia did not have onset in service and was less likely than not related to service. In January 2017, the Veteran underwent a second VA contract examination. She reported constant abdominal pain and used a compression wrap around the abdomen. The examiner noted no previous surgery was performed on the umbilical hernia, but that it appeared operable and remediable. The examiner opined that the umbilical hernia was less likely than not related to service or due to the in-service C-section procedure. The rationale was that she had a low transverse incision with the C-section and reported incisional pain in the same area. A low transverse incision would not cause either the diastasis recti or the umbilical hernia that was diagnosed by the CT scan. None of the treating clinicians have suggested such an association between the C-section and the umbilical hernia. Moreover, the examiner found that the service treatment records did not document an in-service injury or condition that likely resulted in or predisposed the Veteran to develop an umbilical hernia. Given the above, the Board finds that service connection is not warranted for the reasons stated below. The competent and probative medical evidence is against a nexus between the Veteran’s umbilical hernia and active service, to include as due to the in-service C-section procedure. The service treatment records do not show a diagnosis of a hernia. The earliest clinical evidence of diagnosed umbilical hernia was not until almost 5 years after service. Also, the January 2017 VA contract examiner reviewed the claims file, discussed the clinical findings, and determined the umbilical hernia did not have onset in service and was not otherwise related to service, to include as due to the in-service C-section procedure. The examiner supported the opinion with a cogent rationale, to which the Board assigns great probative value. There is no competent evidence to the contrary. As the probative medical evidence does not show a causal relationship between service and the current umbilical hernia condition, service connection is not warranted. While the Veteran may truly believe that her umbilical hernia is related to service, to include as due to her in-service C-section procedure, she has not shown the medical expertise or knowledge to provide such a determination. See Davidson, supra; Jandreau, supra. As the Veteran is a lay person without specialized medical knowledge and training to diagnose and evaluate internal physiological processes such as an umbilical hernia, her lay assertions as to onset and etiology are not competent and thus not probative. In sum, as the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. Service connection for an umbilical hernia is not warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990).   REASONS FOR REMAND 2. Entitlement to service connection to a cesarean section (C-section) scar is remanded. The Veteran seeks service connection for a scar acquired during an emergency C-section procedure performed during service. See August 2015 notice of disagreement. She contends that the scar is painful. See August 2017 VA Form 9. It is undisputed that the Veteran delivered a child via C-section in July 2008, which was during her active service period. The C-section involved a low transverse incision to the abdomen. A week after separation from service in September 2008, she was seen in the emergency room for post C-section incisional pain. The Veteran was afforded VA contract examinations for scars in March 2015 and in January 2017; however, neither examination reflects any relevant scar findings. Thus, this issue is remanded for an examination. The matter is REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of a C-section. (Continued on the next page)   The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including her emergency C-section procedure in July 2008. All relevant findings should be included. The examiner should also provide a rationale for any opinion offered. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Tang, Associate Counsel