Citation Nr: 21064513 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 17-34 308 DATE: October 20, 2021 ORDER Entitlement to an effective date earlier than March 20, 2014, for the grant of service connection for interstitial lung disease is denied. But a higher 30 percent initial rating for the interstitial lung disease is granted as of March 20, 2014. Moreover, an even higher 60 percent rating, though no greater, is granted for the interstitial lung disease as of July 12, 2016. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to the interstitial lung disease, is granted. Entitlement to service connection for headaches, to include as secondary to the OSA, is granted. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for a right leg disability is denied. Entitlement to service connection for a left leg disability is denied. Entitlement to service connection for a neck disability is denied. Entitlement to service connection for a right hip disability is denied. Entitlement to service connection for a left hip disability is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for lumbar spinal stenosis is denied. Entitlement to service connection for hypertension is denied. FINDINGS OF FACT 1. The Veteran did not file a claim of entitlement to service connection for lung disease of any sort within a year of his discharge from service and did not claim entitlement to service connection for interstitial lung disease due to asbestos exposure until March 20, 2014. 2. However, as of March 20, 2014, the Veteran's pulmonary function tests (PFTs), assessing the extent and severity of his interstitial lung disease, show a Diffusion Capacity of Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 64% predicted. 3. From July 12, 2016 onward, his PFTs show a DLCO (SB) of 55% predicted, but not worse. 4. His OSA is caused or aggravated by his service-connected interstitial lung disease. 5. His headaches are caused or aggravated by his now service-connected OSA. 6. The preponderance of the evidence is against finding that the Veteran's tinnitus, hypertension, bilateral leg disability, neck disability, bilateral hip disability, bilateral shoulder disability, bilateral knee disability, or lumbar spinal stenosis began during his active military service, onset within one year of his separation from service, or are otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria are not met for an effective date earlier than March 20, 2014, for the grant of service connection for the interstitial lung disease. 38 U.S.C. §§ 5101(a), 5110; 38 C.F.R. §§ 3.1(p), 3.151(a), 3.155; 3.400, 3.816. 2. But the criteria are met for a higher 30 percent initial rating, though no greater, for the interstitial lung disease as of March 20, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.21, 4.31, 4.97, Diagnostic Code (DC) 6833. 3. The criteria also are met for an even higher 60 percent rating, though no greater, for the interstitial lung disease since July 12, 2016. Id. 4. The criteria are met for entitlement to service connection for OSA as secondary to the interstitial lung disease. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria are met for entitlement to service connection for headaches as secondary to the now service connected OSA. Id. 6. But the criteria are not met for entitlement to service connection for tinnitus, hypertension, bilateral leg disability, neck disability, bilateral hip disability, bilateral shoulder disability, bilateral knee disability, or lumbar spinal stenosis. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1971 to March 1972. This appeal to the Board of Veterans' Appeals (Board) is from an August 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This case previously was before the Board in March 2019, at which time the claims were remanded back to the RO (Agency of Original Jurisdiction (AOJ)) for further development and consideration including to obtain and associate with the file VA treatment records from the Baltimore VA Medical Center (VAMC) dated from 1996 to 2015. That remand instruction since has been completed, as directed. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions); but see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only "substantial" rather than strict or exact compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). There is one other preliminary point also worth mentioning. In his February 2017 Notice of Disagreement (NOD), the Veteran, through his attorney, indicated they additionally were appealing a supposed denial of service connection for a mental health condition. However, this other claim was not adjudicated in the rating decision on appeal, or in any rating decision for that matter, as the Veteran withdrew that claim in June 2016. This means the claim was withdrawn prior to any decision being made on the matter; thus, there is no decision concerning service connection for a mental health condition to appeal. The issue of entitlement to service connection for a mental health condition resultantly is not before this Board and consequently will not be discussed further in this decision. Earlier Effective Date 1. Entitlement to an earlier effective date for the award of service connection for interstitial lung disease The Veteran has made a general claim that he is entitled to an effective date prior to March 20, 2014 for the grant of service connection for his interstitial lung disease. The first thing worth pointing out is that the effective date for an award of service connection is not generally predicated on the date of medical or other evidence showing or suggesting the Veteran had the condition at issue or even commonly associated symptoms, instead, it is based on when he actually filed a claim for the condition. In other words, in the absence of a sufficient manifestation of an intent to apply for benefits for a particular disease or injury, a document providing medical information in and of itself is not an informal claim for VA benefits. See Ellington v. Nicholson, 22 Vet. App. 141 (2007). The general rule for an effective date for service connection provides that, if a claim for disability compensation is received within one year after separation from service, the effective date of entitlement will be either the day following separation from service or the date entitlement arose. 38 U.S.C. § 5110(b)(1). Here, there is no contention that a claim for interstitial lung disease was received within a year of the Veteran's separation from service in March 1972, so by March 1973. A specific claim in the form prescribed by the Secretary of VA must be filed in order for benefits to be paid to any individual under the laws administered by the VA. 38 U.S.C. § 5101(a). A "claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p); Brannon v. West, 12 Vet. App. 32, 34-5 (1998). Any communication indicating an intent to apply for a benefit under the laws administered by VA may be considered an informal claim provided it identifies, but not necessarily with specificity, the benefit sought. See 38 C.F.R. § 3.155(a). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). Consider also however that, effective March 24, 2015, VA amended its regulations to require that all claims governed by VA's adjudication regulations be filed on a standard form. The amendments implement the concept of an intent to file a claim for benefits, which operates similarly to the informal claim process, but requires that the submission establishing a claimant's effective date of benefits must be received in one of three specified formats. The amendments also eliminated the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims under 38 C.F.R. § 3.157. See 79 Fed. Reg. 57660 (Sept. 25, 2014). When a prior unappealed decision becomes final and binding on a Veteran, the effective date of a subsequent award of service connection is the date of receipt of the reopened claim, not the date of receipt of the original claim. Sears v. Principi, 16 Vet. App. 244 (2002); Melton v. West, 13 Vet. App. 442 (2000). Here, a review of the record on appeal shows that, on March 20, 2014, the Veteran submitted VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. On this form, he indicated that he was claiming entitlement to service connection for, among other disabilities, a "respiratory condition (asbestos on ship)." A review of the record shows that, prior to that March 20, 2014 application, the Veteran had not submitted anything to VA indicating an intent to file a claim for interstitial lung disease. In March 1973, he started using his VA education benefits and later, in 1982, file a claim requesting extension of those education benefits. The next contact unrelated to the education benefits was a September 1991 request for a copy of his DD Form 214. The next document in the claims file after that is the March 20, 2014 application for benefits, including the claim for service connection for interstitial lung disease, which he characterized more generally as a respiratory condition owing to exposure to asbestos. As such, March 20, 2014, the date VA received the Veteran's initial claim for this disability, is the proper effective date for the later award of service connection for interstitial lung disease. His claim for an earlier effective date resultantly is denied. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When evaluating the severity of a disability, it is essential the disability is considered in the context of its entire recorded history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). But if the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings, then separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings and is employed for initial or established ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In general, it is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's interstitial lung disease is rated under DC 6833, for asbestosis, as it was found to be the result of his potential exposure to asbestos during his military service. DC 6833 is part of the General Formula for Interstitial Lung Disease. 38 C.F.R. § 4.97, DC 6833. Under the General Formula for Interstitial Lung Disease, a 10 percent rating is warranted for a Forced Vital Capacity (FVC) of 75- to 80-percent predicted, or; Diffusion Capacity of Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) of 66- to 80-percent predicted. A 30 percent rating is warranted for FVC of 65- to 74-percent predicted, or; DLCO (SB) of 56- to 65-percent predicted. A 60 percent rating is warranted for FVC of 50- to 64-percent predicted, or; DLCO (SB) of 40- to 55-percent predicted, or; maximum exercise capacity of 15 to 20 ml/kg in oxygen consumption with cardiorespiratory limitation. A 100 percent rating is warranted for FVC less than 50-percent predicted, or; DLCO (SB) less than 40-percent predicted, or; maximum exercise capacity less than 15 ml/kg in oxygen consumption with cardiorespiratory limitation, or; cor pulmonale or pulmonary hypertension, or; requires outpatient oxygen therapy. 38 C.F.R. § 4.97, General Rating Formula for Interstitial Lung Disease (DCs 6825 through 6833). 2. A higher 30 percent initial rating is granted for the interstitial lung disease as of March 20, 2014 The Veteran has a 0 percent (noncompensable) rating for his interstitial lung disease dating from the receipt of his claim for service connection for this condition on March 20, 2014. In July 2015, the Veteran underwent a VA respiratory conditions examination. The examination report shows that he had FVC of 3.45% predicted and that his DLCO (SB) was 21.8%. However, this appears to be a mistake, as the examiner also included the results of the PFT showing the Veteran's FVC reference number was 3.45, which reflected 87% predicted and that his DLCO was 21.8, which reflected 64% predicted. The Veteran's July 2015 DLCO of 64% supports a higher 30 percent initial rating for his interstitial lung disease. Moreover, this rating should date back to March 20, 2014, so even prior to that examination, since it is as likely as not that he had this extent of respiratory impairment even when earlier filing his claim for this disease. The U. S. Court of Appeals for Veterans Claims (Court/CAVC) has explained that, in an original claim for service connection, the date entitlement arose is governed by the date the claim is received, not the date of the medical evidence submitted to support a particular claim. See McGrath v. Gober, 14 Vet. App. 28 (2000). 3. An even higher 60 percent rating, though no greater, is granted for the interstitial lung disease from July 12, 2016 onward On July 12, 2016 the Veteran underwent an additional VA respiratory conditions examination. The report of this additional examination shows he had FVC of 72% predicted and DLCO (SB) of 55% predicted. His DLCO reading supports a higher 60 percent rating according to DC 6833. The July 2016 examination report also shows the Veteran did not require outpatient oxygen therapy, and there is no indication he has cor pulmonale or pulmonary hypertension. Pulmonary hypertension is a separate and different diagnosis than hypertension. As such, the July 2016 VA examination supports a higher 60 percent rating for the Veteran's interstitial lung disease, but not an even higher 100 percent rating. Service Connection 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; 38 C.F.R. § 3.303(a). Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or a disease, and (3) a nexus, or link, between the current disability and the disease or injury in service. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Certain "chronic" diseases, including tinnitus, hypertension, and arthritis, also may be presumed to have been incurred in service if they manifested to a compensable degree (generally meaning to at least 10-percent disabling) within a year after the Veteran's separation from service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Here, though, there is no claim that the Veteran's tinnitus, hypertension, or any other chronic disability, per se, onset within one year of his March 1972 separation from service, so by March 1973, and there is no medical evidence otherwise showing an onset of any claimed disability within the year following his separation from service. Service connection may be granted, as well, on a secondary basis for disability that is caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310. 4. Entitlement to service connection for OSA, to include as secondary to the interstitial lung disease The Veteran asserts that his OSA is either proximately due to or aggravated by his service-connected interstitial lung disease. A May 2010 VA treatment record confirms the Veteran has current disability owing to OSA. He also submitted a Disability Benefits Questionnaire (DBQ) in May 2018, completed by a private examiner, Dr. H.S. On this DBQ, Dr. H.S. opined that "the Veteran's service connected interstitial lung disease more likely than not aided in the development of and permanently aggravates his OSA." Thus, upon review of the record, so also the other relevant evidence, the Board finds the evidence to at least be in relative equipoise (meaning as supportive of the claim as against it), if not more favorable to the claim, concerning whether the Veteran's OSA is secondary to his service-connected interstitial lung disease. Certainly then, when resolving all reasonable doubt in his favor concerning this posited correlation, the Board finds that service connection for OSA is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for headaches, to include as secondary to the OSA Further in the posited chain link, the Veteran additionally contends that his OSA, in turn, causes or aggravates his headaches. In May 2018, the Veteran submitted an additional DBQ completed by Dr. H.S. On this DBQ, Dr. H.S. stated that the Veteran has a diagnosis of tension headaches. The Veteran reported having headaches three to four times per week that were caused by "inability to sleep well due to OSA." Dr. H.S. provided an accompanying letter in which he explained that medical research supports that sleep apnea is a major cause of headaches. Dr. H.S. opined that the Veteran's OSA more likely than not both causes and aggravates his headaches. Thus, upon review of the record, so also the other relevant evidence, the Board finds the evidence to at least be in relative equipoise (again, meaning as supportive of the claim as against it), if not more favorable to the claim, concerning whether the Veteran's headaches are secondary to his service connected OSA. Certainly, then, resolving all reasonable doubt in his favor concerning this posited correlation, the Board finds that service connection also is warranted for his headaches. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Entitlement to service connection for tinnitus The Veteran asserts that his tinnitus was caused by his military service, especially repeated exposure to loud noise and consequent injury (acoustic trauma). However, the Board concludes that, while the Veteran is competent to state that he suffers from tinnitus, the preponderance of the evidence is against finding that it began during his active military service, within a year of his discharge from service, or is otherwise related to an in-service injury, event, or disease. The Veteran's service treatment records (STRs) do not contain evidence that he experienced tinnitus at any time while in service either in the way of a relevant subjective complaint (e.g., notable symptom, etc.) or objective clinical finding (pertinent diagnosis). This lack of mention of tinnitus or finding of it includes during his March 1972 separation examination. In cases involving combat, VA is prohibited from drawing a negative inference from silence in the STRs. See Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (cautioning that negative evidence, meaning actual evidence weighing against a party, must not be equated with the absence of substantive evidence). Conversely, in cases, as here, where this inference is not prohibited [i.e., non-combat scenarios], the Board may use silence in the STRs as contradictory evidence if the alleged injury, disease, or related symptoms ordinarily would have been recorded in the STRs. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). See also Bardwell v. Shinseki, 24 Vet. App. 36 (2010) (For non-combat Veterans providing non-medical related lay testimony regarding an event during service [or where, as here, the injury claimed is not alleged to have occurred in combat], the holding in Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006), is distinguishable; the lack of documentation in service records must be weighed against the Veteran's statements.). Buchanan had held that lay evidence such as that proffered by the Veteran and his comrades is potentially competent to support the presence of a disability, even where not corroborated by contemporaneous medical evidence such as actual treatment records (STRs, etc.). In this circumstance, that is, where a claimed injury, disease or event is not alleged to have occurred during combat, the Board must make two preliminary findings to rely on this negative inference (see Kahana): (a) First, the Board must find that the STRs appear to be complete, at least in relevant part. If the STRs are not complete in relevant part, then silence in the STRs is merely the absence of evidence and not substantive negative evidence. (b) If the STRs are complete in relevant part, then the Board must find that injury, disease, or related symptoms ordinarily would have been recorded had they occurred. In making this determination, the Board may be required to consider the limits of its own competence on medical issues. So, it is true the mere absence of evidence does not necessarily equate to unfavorable evidence. Indeed, as mentioned there are a line of precedent cases supporting this proposition. See, e.g., Horn v. Shinseki, 25 Vet. App. 231, 239 (2012); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Buchanan, supra. The Federal Circuit Court also has held however that, while the absence of contemporaneous records does not, in and of itself, render lay testimony not credible, the Board may weigh the absence of contemporaneous records when assessing the credibility of lay evidence. See Buchanan, 451 F.3d at 1336 ("Nor do we hold that the Board cannot weigh the absence of contemporaneous medical evidence against the lay evidence of record."). Moreover, although the Board cannot reject a claimant's statements merely because he is an interested party, the claimant's interest may affect the credibility of his testimony when considered in light of other factors. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991); accord Buchanan, 451 F.3d at 1337 (holding that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias . . . ."). Here, the Veteran served during the Vietnam era, and his service personnel records (SPRs) show that he served on the USS Dixie. However, there is no indication that he engaged in combat or that the USS Dixie was deployed (i.e., not stateside) while he was stationed aboard the ship. His SPRs and DD Form 214 do not indicate that he engaged in combat. A finding that he engaged in combat with the enemy requires that he participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality and does not apply to Veterans who served in a general "combat area" or "combat zone" but did not themselves engage in combat with the enemy. See VAOPGCPREC 12-99 (October 18, 1999). Further, there is no suggestion the Veteran's STRs are incomplete at least in relevant part. So, the fact that he did not complain of tinnitus while in service and did not receive this diagnosis is probative indication that he did not have this condition while in service. Indeed, there is no evidence, medical or otherwise, showing a complaint of tinnitus for over 37 years following the Veteran's separation from service, so for more than three and a half decades. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (ruling that a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service resulting in any chronic or persistent disability). See also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming the Board's denial of service connection where the Veteran-claimant had failed to account for lengthy time period between service and initial symptoms of disability). Tinnitus is "a noise in the ear, such as ringing, buzzing, roaring, or clicking." See Dorland's Illustrated Medical Dictionary 1714 (28th ed. 1994). Tinnitus is often subjective in nature; indeed, because of its inherently subjective nature, even a layman such as the Veteran is considered competent to report the observable manifestations of this condition like this ringing, buzzing, roaring, or clicking sound mentioned. He is competent to provide evidence regarding tinnitus, as it is a condition readily apparent through the senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994) (a Veteran is competent to report symptoms that require only personal knowledge, not medical expertise, as they come to him through his senses). Because tinnitus is "subjective," its existence is generally determined by whether the claimant claims to experience it. Indeed, for VA purposes, tinnitus has been specifically found to be a disorder with symptoms that can be identified through lay observation alone. See Charles v. Principi, 16 Vet. App. 370 (2002). This means tinnitus is the type of chronic condition, per se, since contemplated by 38 C.F.R. § 3.309(a), which the Veteran can establish is related to or the result of his service by showing continuity of symptomology since his service under the provisions of 38 C.F.R. § 3.303(b). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, the Veteran's treatment records are grossly unremarkable for subjective complaints of tinnitus, much less objective confirmation of it for many years after conclusion of his service. As already alluded to, there was some 37 years between his separation from military service and his reported onset of tinnitus in 2009. The Veteran underwent a VA tinnitus examination in June 2016. At this examination he stated that he first started experiencing tinnitus in 2009, so 37 years after his separation from service. The medical evidence of record, including especially the Veteran's own statements, does not support the notion that tinnitus has been ongoing since the Veteran's time in the military. The Board finds that any assertion now contrarily being made that the Veteran suffers from tinnitus related to his military service or that he has experienced this condition continuously since his service is undermined and outweighed by the more probative (more competent and credible) medical evidence of record indicating a far more recent inception of this disease. The totality of the evidence does not show that the onset of any current tinnitus occurred during his service or within one year of his discharge from service. The Board finds it most telling that the Veteran stated his tinnitus onset in 2009, 37 years after his separation from service. Further, the June 2016 VA examiner opined that it was less likely than not that the Veteran's tinnitus was related to his military service. The examiner pointed out the delayed onset 37 years and then pointed to medical research stating that based on current understanding of cochlear physiology, there is no evidence for the delayed onset of tinnitus. Thus, although this disease as mentioned is subjective in nature, as explained by the VA examiner, absent indication of tinnitus in service or for many years following separation, there is not the required finding of tinnitus owing to the Veteran's service. The service records and post-service records do not support his contentions of his tinnitus dating back to his service or being the result of his service. Accordingly, his claim for service connection for tinnitus is denied. Moreover, there is no reasonable doubt to resolve in his favor concerning these determinative issues, so the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Entitlement to service connection for hypertension 8. Entitlement to service connection for a right leg disability 9. Entitlement to service connection for a left leg disability 10. Entitlement to service connection for a neck disability 11. Entitlement to service connection for a right hip disability 12. Entitlement to service connection for a left hip disability 13. Entitlement to service connection for a right shoulder disability 14. Entitlement to service connection for a left shoulder disability 15. Entitlement to service connection for a right knee disability 16. Entitlement to service connection for a left knee disability 17. Entitlement to service connection for lumbar spinal stenosis The Veteran has made a blanket, generalized assertion that his hypertension, bilateral leg disability, neck disability, bilateral hip disability, bilateral shoulder disability, bilateral knee disability, and lumbar spinal stenosis are related to his active service. The Veteran has not made more specific contentions in support of these claims for service connection. The Veteran's STRs are grossly unremarkable for complaints, treatment, or diagnosis of hypertension or for impairment referable to his legs, neck, hips, shoulders, knees, or lumbar spine. During his March 1972 separation examination, he denied, and the examiner found no evidence of, any leg, neck, hip, shoulder, knee, or lumbar spine disability, and his blood pressure was 132/80 which is not indicative of hypertension. In fact, upon examination for separation, the only note of significant medical history was that he "has had flashbacks secondary to LSD usage." There was no suggestion he had any disability, pain, or other symptom owing to hypertension or in reference to his legs, neck, hips, shoulders, knees, or lumbar spine. Among post-service VA treatment records dating since January 1996, the evidence shows that, in July 2009, the Veteran denied any prior neck or cervical spine injury. Concerning his lumbar spine, knees, hips, and legs, the Veteran reported an onset of lumbar spine pain in either January or February 2009, so 37 years after his separation from service, and he attributed the onset to "no apparent reason." He further stated that this lumbar spine pain was radiating to his right thigh. There were no significant degenerative changes to the Veteran's lumbar spine noted on an x-ray taken that same month. Further, that same November 2009 VA treatment record shows that the Veteran had full range of motion in his knees and hips. Concerning the Veteran's hypertension, VA treatment records from 1996 show that he had no diagnosis for hypertension. There was a gap in treatment until the Veteran returned to VA for care in March 2009, at which time he was seeking a refill of his prescription hypertension medicine. This suggests that the Veteran was diagnosed with hypertension sometime between 1996 and 2009, more than one year after his separation from service in 1972. A November 2013 VA treatment record shows that the Veteran's low back pain and knee pain were attributed to his obesity and osteoarthritis. The VA treatment records do not contain a specific diagnosis concerning the Veteran's shoulders. Service connection for hypertension, bilateral leg disability, neck disability, bilateral hip disability, bilateral shoulder disability, bilateral knee disability, or lumbar spinal stenosis is not warranted on any basis. Service connection must be denied as directly related to military service because the evidence of record shows none of these disabilities began during service and there is no competent medical evidence indicating that these disabilities are otherwise related to any in-service disease or injury. In addition, service connection for these disabilities is not warranted on a presumptive basis under the provisions relating to chronic diseases at 38 C.F.R. § 3.309(a) because none of these disabilities that could fall under this presumption manifested to a compensable degree within one year of separation from service. Instead, the evidence shows that hypertension was diagnosed sometime after 1996, which is at a minimum 24 years after his separation from service; and the Veteran reported an onset of lumbar spine pain and associated thigh and leg pain onset in 2009, so 37 years after his separation from service. VA treatment records do not contain specific diagnoses for any shoulder disability, hip disability, leg disability, or cervical spine disability, other than a blanket osteoarthritis notation, but the November 2013 VA treatment record specifies that his osteoarthritis was causing lumbar spine and knee pain. Ultimately, there is no probative evidence indicating the Veteran's hypertension, bilateral leg disability, neck disability, bilateral hip disability, bilateral shoulder disability, bilateral knee disability, or lumbar spinal stenosis are related to or the result of his military service. No VA examination and/or medical opinion is required concerning these claims in this circumstance. McLendon v. Nicholson, 20 Vet. App. 70 (2006). Generalized lay allegations, such as the Veteran's general claim of entitlement to service connection for hypertension, bilateral leg disability, neck disability, bilateral hip disability, bilateral shoulder disability, bilateral knee disability, or lumbar spinal stenosis merely by listing them on his application for compensation are insufficient to meet the McLendon standards, even though supporting medical evidence is not necessarily required. Waters v. Shinseki, 601 F.3d 1274, 1276 (2010). In claims for service connection, VA must provide a medical examination for a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or a service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon, 20 Vet. App. at 81-82. Regarding the third factor, the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence suggesting a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. 79. The even higher Federal Circuit Court also has addressed the appropriate standard to be applied in determining whether an examination is warranted. In both Waters v. Shinseki, supra, and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that, while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, however, a mere conclusory generalized lay statement suggesting a nexus between a current disability and service (as in this case here) would not suffice to meet the standards, as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Thus, as the preponderance of the evidence is against these remaining claims for service connection, the benefit-of-the-doubt doctrine is not applicable, and these claims are denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. KEITH W. ALLEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Pak 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.