Citation Nr: 1816693	
Decision Date: 03/20/18    Archive Date: 03/30/18

DOCKET NO.  14-21 101A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Montgomery, Alabama


THE ISSUE

Entitlement to service connection for hypertension, to include as secondary to service connected posttraumatic stress disorder (PTSD).


REPRESENTATION

Veteran represented by:	Disabled American Veterans


WITNESS AT HEARING ON APPEAL

Veteran


ATTORNEY FOR THE BOARD

R. Kipper, Associate Counsel


INTRODUCTION

The Veteran served on active duty from June 1981 to September 1981 and from October 2004 to November 2005, with additional service in the Army National Guard.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama.

In September 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge.  A transcript of the hearing has been associated with the claims file.


FINDING OF FACT

The evidence is in relative equipoise as to whether the Veteran's hypertension is causally related to his service-connected PTSD.


CONCLUSION OF LAW

Resolving all reasonable doubt in the Veteran's favor, the criteria for establishing entitlement to service connection for hypertension have been met.  38 U.S.C. §§ 1101, 1112, 1131, 5103(a), 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310(a) (2017).


REASONS AND BASES FOR FINDING AND CONCLUSION

I. Duties to Notify and Assist

As the Board's decision to grant the Veteran's claim of entitlement to service connection for hypertension is completely favorable, no further action with respect to such issue is required to comply with the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations.  See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49747 (1992).

II. Service Connection

The Veteran contends that his hypertension is caused by his service-connected PTSD.  

Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  

Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310.  Secondary service connection is provided for disability that is caused by a service connected disease or disability; or that is aggravated by a service connected disease or disability.  38 C.F.R. § 3.310(a), (b).

The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant.  See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value.

Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied.  38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

In the present case, the Veteran has been diagnosed with hypertension.  See December 2011 VA Examination Report.  Thus, there is evidence of a current disability.  Additionally, the Veteran has service-connected PTSD.

The question then becomes whether a nexus, or relationship, between the Veteran's current disability and the Veteran's service-connected disability has been shown.  The Board notes that there are competing medical opinions of record regarding whether the Veteran's hypertension is related to his PTSD.

In a June 2011 letter, the Veteran's private cardiologist, K.E.F., opined that the Veteran's "problems of control of hypertension have largely been difficult in relation to findings of post-traumatic stress disorder after his deployment in the military."  

In another June 2011 letter, the Veteran's private physician, Dr. J.B.W., opined that the Veteran's PTSD was "directly contributing to his hypertension diagnosis."  Dr. J.B.W. also indicated that the Veteran's stress disorder and situational anxiety "is a significant factor in his underlying hypertension."  He summarized that the Veteran's "hypertension diagnosis in 2007 is more likely directly related to his military service and resulting PTSD."  

The Veteran was afforded a VA examination in December 2011.  The examiner noted a diagnosis of hypertension and opined that it was less likely as not related to PTSD because "[t]here is no medical nexus between the two conditions."  The examiner also noted that the Veteran's risk factors for hypertension were obesity, family history, and ethnicity.  

In an August 2016 letter, Dr. K.E.F., opined that the Veteran's hypertension was more likely caused by or the result of PTSD.

In an October 2017 letter, Dr. J.B.W. reiterated his opinion that the Veteran's hypertension was related to his PTSD.  He opined that the Veteran's "anxiety/PTSD is related to his hypertension diagnosis."  He further indicated that "it is directly contributing to his diagnosis."  He noted that the Veteran's PTSD was diagnosed in December 2005, which preceded his diagnosis of hypertension.  He summarized that the Veteran's hypertension and PTSD "are both definitively and directed correlated."  

Here, the December 2011 VA examiner reviewed the claims file and provided a rationale for the negative nexus opinion, but did not account for the private opinions of record and did not explain why PTSD could not be a hypertension risk factor for this Veteran.  The Board notes that it is not clear whether the treating physicians reviewed the Veteran's claims file.  However, the record reflects that they were familiar with the Veteran's medical history and that they did not rely upon any assumptions or information that would be inconsistent with the evidence in the claims-file.  Specifically, the physicians were equally aware of the Veteran's other risk factors for hypertension, but still opined that the Veteran's hypertension was due to his PTSD.  Thus, the opinions remain probative.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).  

That said, the Board finds no adequate reason to favor the negative opinion over the positive opinions that are favorable to the Veteran's claim.  Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (in evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility and probative value of proffered evidence in the context of the record as a whole); Evans v. West, 12 Vet. App. 22, 26 (1998).  Accordingly, the Board finds that the positive and the negative opinions put the evidence in relative equipoise as to whether the Veteran's hypertension is due to his service-connected PTSD.  When the evidence for and against the claim is in relative equipoise, by law, the Board must resolve all reasonable doubt in favor of the claimant.  38 U.S.C. § 5107; 38 C.F.R. § 3.102.

Based on the foregoing and resolving all doubt in the Veteran's favor, the Board finds that entitlement to service connection for hypertension is warranted, as secondary to service-connected PTSD.  38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).


ORDER

Entitlement to service connection for hypertension as secondary to service-connected PTSD is granted.



____________________________________________
TANYA SMITH
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs