Citation Nr: 20029210 Decision Date: 04/27/20 Archive Date: 04/27/20 DOCKET NO. 12-20 844 DATE: April 27, 2020 ISSUE Entitlement to service connection for hypertension, to include as secondary to a service-connected bilateral knee disability. REMANDED Entitlement to service connection for hypertension, to include as secondary to a service-connected bilateral knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from June 1976 to June 1978. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at an August 2016 Board video conference hearing. A transcript of that hearing has been associated with the claims file. The Veteran was scheduled for a Board video conference hearing before the undersigned VLJ on January 29, 2019 but did not appear for the hearing. There is no evidence of good cause for the Veteran's failure to appear at the schedule hearing. In June 2019, the Board remanded this matter for further development and adjudication. The Board specifically remanded this matter for a VA addendum opinion. That opinion was rendered in January 2020. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900 (c). 38 U.S.C. § 7107 (a)(2). Entitlement to service connection for hypertension, to include as secondary to a service-connected bilateral knee disability is remanded. The Veteran has claimed that his hypertension is related to his active duty service. He has also claimed that his hypertension has been aggravated by the medication he takes for his service-connected bilateral knee disability. More recently, the Veteran has also claimed that his hypertension has been aggravated due to the “lengthy claims process” of VA compensation. To establish an entitlement to service connection, the Veteran must establish (1) the existence of a present disability, (2) an in-service occurrence 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. 38 C.F.R. § § 3.303(a). Service connection may also be granted as secondary to a currently service-connected disability. To meet the criteria for secondary service connection, a Veteran must prove that there is (1) a current disability that is not already service-connected; and (2) at least one service-connected disability; and (3) evidence that the non-service connected disability is either proximately due to or the result of a service-connected disability, or aggravated (increased in severity) beyond its natural progress by a service connected disability. 38 C.F.R. § 3.310; Allen v. Brown 7 Vet. App. 439 (1995). The Veteran testified at the August 2016 hearing that the racial discrimination and harassment he experienced in service contributed to his hypertension and depression, as has the VA claims process. The Veteran stated that he was internalizing his stress from his poor treatment in service for years. He testified that at times he couldn’t sleep due to thinking about what he went through and the anger “took its toll.” The Veteran then stated that he is “inadequate to do the things that [he] once did” due to his knee disability which aggravates his depression. By way of background, the Board found that a July 2015 VA examination, which denied the etiological link between the Veteran’s hypertension and his service was inadequate. The Board remanded the issue of entitlement to service connection for hypertension in November 2016 for further development and clarification of the July 2015 examinations. An addendum to the July 2015 VA hypertension examination was obtained in January 2017. The VA examiner opined that it is less likely than not that the Veteran’s hypertension was caused or aggravated by the Veteran’s service or his service-connected bilateral knee disability, to include stress and medications associated with the knee pain. The rationale was that arthritis-related pain, stress, or medications associated with knee pain are not risk factors for essential hypertension “as per the medical literature.” The Board notes that this opinion did not address the lay contentions made by the Veteran, nor did it address whether the Veteran’s hypertension is related to the lengthy claims process through VA. As a result, the Board remanded this matter again in November 2017 for an additional opinion. From that November 2017 remand, the Veteran was afforded a VA examination in April 2019. The examiner noted that the Veteran was diagnosed with hypertension in 2010, that he had a family history of hypertension and smoked half a pack of cigarettes per day for the last 30 years. The examiner opined that it is less likely than not that the Veteran’s hypertension is related to military service and is less likely aggravated by his service-connected knee disability. The examiner’s rationale was based on the fact that he had discussed with the Veteran regarding his service connected knee disability, considered his complaints of racial abuse in the service, reviewed his psychiatry C&P examination, reviewed previous C&P medical exams and the Veteran’s statement of family history of hypertension and reviewed the risk factors of hypertension in up to date medical literature. Most recently, the Board found the April 2019 rationale inadequate, as it merely listed the evidence which was reviewed, but did not explain how that information was relevant for the Veteran’s personal situation, nor did it provide an analysis for how that listed information led to the examiner’s conclusion as to the etiology of the Veteran’s hypertension. Furthermore, the Board noted that the April 2019 examiner made no mention as to the Veteran’s claim that his hypertension was due to stress caused by the lengthy claims process through VA, which was specifically mentioned in the remand directives. As such, the June 2019 Board decision remanded the matter again. In the June 2019 Board remand directives, an addendum opinion was to be obtained that opined as to the Veteran’s claim of hypertension, as it related to (1) racial abuse incurred during his active duty service, (2) medication and depression related to his service-connected bilateral knee disability, and/or (3) the stress due to the lengthy VA claims process. The June 2019 Board remand directives specifically stated that “simply listing those factors is not adequate.” Most recently, an addendum opinion was obtained in January 2020. The VA physician indicated that the Veteran’s claims file was reviewed. The VA examiner stated that the Veteran’s hypertension was less likely than not relate to racial abuse in service, nor was it aggravated by “stress and medications associated with his [service connected] knee disability.” The following rationale was provided: As per review of previous C&P medical exams along with review of psychiatry C&P exams from different providers including review of psychiatry C&P medical opinion from [February 2017], review of [service medical records], Veteran’s statement of family history of hypertension, as per review of risk factors for hypertension in up to date medical literature and as per my medical experience. Unfortunately, the January 2020 VA addendum opinion is inadequate. While it denied the etiological links for the Veteran’s hypertension due to racial abuse in service, as well as stress and medication for his service-connected bilateral knee disability, the Veteran’s claim as to the length of the VA claims process was not mentioned whatsoever. Furthermore, the Board provided specific instructions in its remand directives that a list of factors would not be adequate. The Board finds that the rationale provided is, essentially, a list of factors. No further explanation is provided for the brief rationale. And just as the rationale did in the April 2019 opinion, the January 2020 opinion does not indicate how that listed information led to the examiner’s conclusion to deny the etiology of the Veteran’s hypertension. Importantly, when VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes. Barr v. Nicholson, 21 Vet. App. 303 (2007). Furthermore, because the Veteran's entire history is reviewed when making disability evaluations, the record must be complete for such service connection determinations to be made. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The January 2020 VA addendum opinion is inadequate. Therefore, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim for an entitlement to service connection so that he is afforded every possible consideration. 38 U.S.C. § 5103 (A); 38 C.F.R. § 3.159. The matters are REMANDED for the following action: 1. Send the Veteran’s claims file, including a copy of this Remand to a VA examiner or appropriate clinician for an addendum opinion. The clinician is to review the Veteran’s claims file, as well as a copy of this remand, and must indicate that such review took place. After such review has taken place, the clinician is asked to opine as to the following: (a.) For the Veteran’s confirmed diagnosis of hypertension, is that diagnosis at least as likely as not related to an in-service injury, event, or disease in service, to include his claims of stress due to racial abuse incurred during his time in service? (b.) If not, is the Veteran’s diagnosed hypertension at least as likely as not related to the lengthy VA claims process? (c.) If not, is it at least as likely as not that the Veteran’s hypertension is (1) proximately due to the Veteran’s service-connected bilateral knee disabilities, or (2) aggravated beyond its natural progression by the service-connected bilateral knee disabilities? Note that the Veteran has claimed that his hypertension may be due to the stress, depression and/or medication taken in conjunction with his service-connected knee disabilities, and not just the musculoskeletal disability itself. All opinions provided must be thoroughly explained, and a complete and detailed rationale for any conclusions reached should be provided (a bare conclusory statement will be deemed inadequate). The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). Importantly, the clinician is reminded that simply listing factors will be deemed inadequate. Any/all factors associated with hypertension must be related to the Veteran’s specific situation, and the rationale must detail how any/all listed factors further the basis for the examiner’s etiological conclusion. 2. If, after completing the requested actions and all additional development deemed warranted, the benefits sought remain denied, furnish to the Veteran a Supplemental Statement of the Case and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Mulrain, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.