Citation Nr: 21064167 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 19-22 614 DATE: October 19, 2021 REMANDED The claim for service connection for a respiratory/pulmonary disability, to include chronic bronchitis, chronic obstructive pulmonary disease (COPD), and interstitial lung disease (ILD), is remanded. REASONS FOR REMAND The Veteran honorably served on active duty from March 1961 to September 1964. In an August 2018 rating decision, the Regional Office (RO) declined reopening an unappealed previously decided claim for service connection for chronic bronchitis and denied his new claim for service connection for COPD. The Veteran appealed. In June 2020, the Board reopened the claim for bronchitis and then remanded both claims for an etiological opinion obtained in August 2021. Concurrently, the RO issued a supplemental statement of the case explaining the reasons for affirming its prior decisions and returned the appeal to the Board. Upon reviewing the evidence of record, the Board has found that an addendum medical opinion is necessary to decide the claim. Of preliminary note, an August 2021 VA examination report reflects a diagnosis of IDL, which the Veteran did not specifically claim. Nonetheless, a veteran without specialized medical training is not expected to advance his or her claim with a precision expected of medical professionals. Rather, a veteran is said to have sufficiently filed a claim for benefits by either referring to a disabled body system or describing the associated symptoms. See DeLisio v. Shinseki, 25 Vet. App. 45, 53 (2011). To that end, instead of focusing on how precisely the claim is worded, the Board must consider the claim as a whole and view it in light of the description of the symptoms, so as to meaningfully understand the nature of the claimed disability. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In accordance with the law, given the evidence of the clinically diagnosed IDL and medical literature submitted in support of claim reflecting that the symptom manifestations of different respiratory and pulmonary conditions might be indistinguishable without a clinical work-up, the Board finds it appropriate to recharacterize the claim as a claim for respiratory/pulmonary disability, to include chronic bronchitis, chronic obstructive pulmonary disease (COPD), and interstitial lung disease (ILD). As reflected in a September 2021 Appellate Brief, the Veteran maintains that his respiratory/pulmonary disability was caused by service, to include his exposure to Toluene which he used to clean torpedoes. However, he believes that the August 2021 negative etiological opinion is inadequate. The Veteran's attorney points out that the rationale for the VA's negative nexus opinion reflected in the August 2021 VA examination report is contradictory. The attorney explains that the examiner acknowledges the already established fact that the Veteran had been exposed to Toluene in service, given his service-connected skin disorder due to Toluene exposure, along with the Veteran's report that he had symptoms of chronic cough, dizziness, and lightheadedness contemporaneously with using Toluene, but then the examiner asserts that the record is devoid of any objective evidence that the Veteran's lungs had been exposed to Toluene or that the Veteran had any symptoms associated with Toluene exposure. The attorney further points out that the VA examiner appears to have applied an excessively high standard of complete medical certainty rather than the well-established relative equipoise in considering whether the Veteran's ILD was caused by service and concluding that this is not the case here because the Veteran was diagnosed with ILD decades after service and the etiology is unknown. The attorney explains that, first, the date of diagnosis is discrete from the date on which the disability arose. Second, the enclosed medical literature discusses pertinent research showing that repeated exposure to Toluene over time does have the adverse respiratory health effects, to include ILD, which effectively undermines the examiner's assertion that the medical literature review did not show that Toluene is a known toxic substance that can cause ILD decades after initial exposure. Further, per enclosed medical literature, research does show that exposure to toluene diisocyanate (TDI) accelerates rate of decline in lung function. With that, the attorney is contending that the August 2021 VA examination report is inadequate. The Board agrees. Once VA undertakes providing a medical examination, the examination itself, its report, and any medical opinions expressed therein, must be adequate. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). See also 38 U.S.C. § 5103A(d); 38 C.F.R. §§ 3.159(c)(4). Of particular note, the VA examination report states that the only reference found in the Veteran's STRs is November 1963 treatment for bronchitis. However, in its June 2020 remand order, the Board specifically noted that the STRs reflect that the Veteran was also treated for bronchitis in February 1962 and then had chest fluid and bronchial drainage in March 1962, which the examiner has not acknowledged. Any medical opinion that is based on an incomplete and erroneous information has little to no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). As such, a new opinion must be obtained. Further, the medical literature unequivocally shows that IDL can be triggered by many different thingsincluding airborne toxins in the workplace. Furthermore, per medical literature, IDL symptomatology is often indistinguishable from other respiratory and pulmonary conditions. While the VA examiner opined that the Veteran does not actually have or ever has had COPD or chronic bronchitis, which is a type of COPD, the record reflects over a dozen of treatments over the years for respiratory symptoms which the examiner attributes to IDL rather than COPD but then opines that the Veteran's treatment in service was for "bronchitis" and thus it is less likely as not that the Veteran's IDL was incurred during service, however, without providing any rationale why at the time of service his symptomatology was more consistent with bronchitis rather than IDL. Ultimately, establishing an entitlement to service connection does not require the evidence to show with clinical certainty that the claimed disability was incurred during service. Rather, the questions before the Board are whether the Veteran's current disability at least as likely as not was incurred in, or was caused by, or otherwise is etiologically related to service, to include having been aggravated by any injury or disease sustained during service. In light of the foregoing discussion, these questions remain unanswered. As such, the Board finds that an addendum medical opinion is necessary to make a fully informed decision. Accordingly, the matters are REMANDED for the following action: Obtain an addendum opinion as to the nature and etiology of the Veteran's respiratory and/or pulmonary disabilities, to include bronchitis, COPD and IDL. If an in-person examination is necessary to answer the Board's questions, one must be provided. The examiner is asked to answer the following questions: a) Is it at least as likely as not (meaning probability of 50 percent or greater) that any pulmonary and/or respiratory disorder(s), however diagnosed, either began in or otherwise were caused by service, to include exposure to Toluene? Why or why not? In so discussing, the examiner should also specifically addressin addition to the Veteran's exposure to Toluene during servicethe Veteran's treatment in 1962 for bronchitis and subsequent bronchial drainage, and whether such are initial manifestations of his current claimed disability. b) If the Veteran is diagnosed with multiple pulmonary and/or respiratory disorder(s) and at least one is determined to be etiologically related to service, is it at least as likely as not (meaning probability of 50 percent or greater) that any subsequently developed disorder(s) were caused by or aggravated (meaning made worse) by the disability etiologically related to service? Why or why not? If aggravation is found, the examiner should establish a baseline severity level prior to the aggravation. If this cannot be established at all or without resorting to speculation, the examiner should explain why. Prior to forming any opinion, the examiner must review the Veteran's entire claims file, to include his service and post-service medical treatment records, his lay statements, scientific literature submitted in support of claim, and this order explaining the reasons why the previously obtained medical opinion was found to be inadequate. The examiner must expressly discuss the Veteran's statements as to the onset and continuity of symptomatology; opine whether, from a medical perspective, the lay reports are medically consistent or inconsistent with the clinical onset of diagnosed disabilities; and explain why. To that end, the examiner should note that a lack of contemporaneous medical treatment records is not the same as affirmative negative evidence and should not be used as a sole basis for rejecting the Veteran's statements. The examiner should provide thorough and sound rationale for every conclusion reached. In that regard, the examiner should discuss the scientific literature of record, cite to any other authority relied upon, abstain from generalized conclusory statements, and connect any general medical knowledge to the compiled data specific to the Veteran's circumstances. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Alex Bardin, 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.