Citation Nr: 18157404 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 14-05 825 DATE: December 12, 2018 ORDER Entitlement to service connection for the cause of the Veteran’s death is granted. Entitlement to dependency and indemnity compensation (DIC) is dismissed as moot. FINDINGS OF FACT 1. The evidence is at least in relative equipoise as to whether the service-connected PTSD contributed substantially and materially to the Veteran’s cause of death. 2. The claim of entitlement to DIC under 38 U.S.C. § 1318 is moot. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Appellant, the criteria for entitlement to service connection for cause of death have been met. 38 U.S.C. §§ 1310, 5107 (2012); 38 C.F.R. §§ 3.102, 3.312 (2018). 2. The Appellant’s claim for DIC benefits pursuant to 38 U.S.C. § 1318 is moot. 38 U.S.C. §§ 1318, 5107 (2012); 38 C.F.R. §§ 3.22, 3.102 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1948 to April 1972 and was awarded the Purple Heart among various other decorations. The Veteran died in November 2011. The appellant is his surviving spouse. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. In August 2016, the Appellant appeared with her attorney and her son at a videoconference hearing before the undersigned. A transcript of that proceeding is associated with the record. In February 2018, the Board sought an advisory medical opinion from the Veterans Health Administration (VHA). 38 U.S.C. § 7109; 38 C.F.R. § 20.901. The medical opinion was received in May 2018 and is associated with the file. A review of the record reflects additional medical evidence was added to the record subsequent to a September 2014 supplemental statement of the case; however, the Appellant’s attorney submitted a waiver of agency of original jurisdiction (AOJ) consideration, in November 2018. As such, no further action is required. As an initial matter, the Board notes that the case has been adjudicated under 38 U.S.C. § 1318, entitlement to DIC. Upon retaining an attorney to provide representation, the Appellant’s claim was amended to include entitlement to service connection for the cause of the Veteran’s death under 38 U.S.C. § 1310 in addition to 38 U.S.C. § 1318. As the Board finds that service connection for the cause of the Veteran’s death is warranted, there is no longer a controversy regarding the benefit sought for the issue of entitlement to DIC benefits under 38 U.S.C. § 1318. Therefore, the claim to entitlement to DIC benefits under 38 U.S.C. § 1318 is dismissed as moot. In light of the favorable decision to grant service connection for the cause of the Veteran’s death, VA’s duties to notify and assist are deemed fully satisfied. There is no prejudice to the Appellant in proceeding to decide the issue. Entitlement to service connection for cause of death A surviving spouse of a qualified Veteran who died as a result of a service-connected disability is entitled to receive DIC. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. To warrant service connection for the cause of the Veteran’s death, the evidence must show that a service-connected disability was either the principal or contributory cause of death. A service-connected disability is considered the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. A service-connected disability is considered the contributory cause of death when it contributed substantially or materially to death, combined to cause death, or aided or lent assistance to the production of death. Id. The Appellant contends that the Veteran’s service-connected PTSD contributed substantially and materially to his cause of death, end-stage cardiac disease. The Appellant, as noted on her appeal to the Board, also contends that the Veteran received diagnoses of Lewy body dementia, which the Appellant claims includes Parkinson’s disease dementia, and ischemic heart disease due to his exposure to Agent Orange while serving in Vietnam. However, as the evidence is at least in relative equipoise as to whether the Veteran’s service-connected PTSD contributed substantially and materially to his cause of death, this is deemed a full grant of the benefits sought on appeal, and therefore, the Board will not address the additional theories of entitlement. A certificate of death reflects that the Veteran died in November 2011. It further reflects that the immediate cause of death was end stage cardiac disease. No underlying cause was noted. Medical treatment records from March 2007 to November 2011 indicate that the Veteran received diagnoses of hypertension in April 1998 and atrial fibrillation in March 1999. At the time of the Veteran’s death, service connection was in effect for posttraumatic stress disorder (PTSD) with major depressive disorder, residuals for prostate cancer, psoriasis, and lumbosacral strain. During the Board hearing, the Appellant’s son testified that it appeared as though the Veteran’s psychiatric symptoms were related to his cardiac symptoms. Specifically, symptoms of one disability worsened in conjunction with the other. The Appellant provided a medical evaluation regarding the Veteran’s cause of death, dated in April 2015. The opinion provided that it was at least as likely as not that Veteran’s death was related to his service-connected impairments, reasoning that the Veteran suffered from long-standing PTSD and stress increases blood pressure and heart rate, contributing to the development of arrhythmias including atrial fibrillation. The Board obtained a VHA opinion in May 2018, addressing the question of whether PTSD caused, or contributed substantially or materially, to the Veteran’s cause of death, end stage cardiac disease. The VHA examiner opined that it was not 50 percent or greater probability that the Veteran’s PTSD caused, or contributed substantially or materially, to the Veteran’s cause of death, end stage cardiac disease. The examiner reasoned that the Veteran’s ability to work for many years in a correctional facility after separating from the military suggested that his PTSD was stable, and later in life, the Veteran’s blood pressure was borderline at most and well controlled with minimum medication. The examiner noted that there was no evidence of an effect of hypertension on the Veteran’s heart. The examiner’s rationale also noted that there were other stronger etiologies for atrial fibrillation including age greater than 60 years, obstructive sleep apnea as suggested by his snoring, and rheumatic vulvar heart disease with mitral valve disorder resulting in significant left atrial enlargement from years of exposure to strep infections. The Appellant provided another independent medical evaluation dated in October 2018. The physician opined that it was at least as likely as not that the Veteran’s PTSD with major depressive disorder, contributed substantially and materially to his cause of death, end stage cardiac disease, reasoning that the Veteran’s PTSD was a longstanding illness that impacted his cardiac condition, specifically leading to and/or aggravating his chronic atrial fibrillation. The physician noted the VHA examiner’s opinion and indicated that PTSD has been specifically correlated to the development of atrial fibrillation and although the Veteran had other conditions that could be related to arrhythmia, mitral regurgitation and obstructive sleep apnea did not rule out PTSD as a direct cause of his chronic atrial fibrillation. The evaluation also indicates that from 1998 and until the time of his death, the Veteran had increased complaints related to his atrial fibrillation, which has been extensively related to heart failure in medical literature. The Appellant also submitted several medical articles that show a link between heart disease and PTSD or its associated symptoms. The Board notes, however, the articles are a general reference and do not specifically address the Veteran’s medical situation. As such, this evidence is of limited probative value. The Board finds the October 2018 independent medical opinion to be the most probative evidence of record. The physician thoroughly reviewed the Veteran’s medical records and the VHA opinion, noting disagreement with the VHA opinion and providing a supporting rationale. The physician also cited numerous medical journals in support of the opinion. Therefore, the evidence is at least in relative equipoise as to whether the Veteran’s PTSD contributed substantially or materially to his cause of death. Thus, resolving all reasonable doubt in the Appellant’s favor, service connection for the cause of the Veteran’s death is warranted. 38 U.S.C. §§ 1318, 5107 (2012); 38 C.F.R. §§ 3.22, 3.102 (2018). THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Hite, Associate Counsel