Citation Nr: 21066927 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 15-41 078A DATE: November 2, 2021 ORDER Entitlement to service connection for cause of the Veteran's death is granted. FINDINGS OF FACT 1. The Veteran's service-connected anxiety was undiagnosed posttraumatic stress disorder (PTSD). 2. The Veteran's PTSD contributed substantially to the coronary occlusion that caused the Veteran's death. CONCLUSION OF LAW The criteria have been met for entitlement to service connection for cause of the Veteran's death. 38 U.S.C. §§ 1110, 1112, 1137, 1310, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from October 1943 to December 1945. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). The Veteran died in January 1980. The appellant is the Veteran's surviving spouse. This issue was previously before the Board in July 2019 and May 2021, when it was remanded for further development. That development was completed, and the case has since been returned to the Board for appellate review. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Considering the Board's favorable decision, however, any deficiencies in VA's duties to notify and assist the appellant with her claim decided herein are moot. Cause of death Legal Criteria Dependency and Indemnity Compensation benefits are payable to the surviving spouse of a Veteran if the Veteran died from a service-connected disability. 38 U.S.C. § 1310(a); 38 C.F.R. § 3.5(a)(1). In order to establish service connection for the cause of a Veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 C.F.R. § 3.312(a). To constitute the contributory cause of death, it must be shown that the service-connected disability contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death.38 C.F.R. § 3.312(c)(1). Factual Background The Veteran's death certificate lists his immediate cause of death as coronary occlusion due to arteriosclerotic heart disease. On the November 2013 claim, the appellant stated that the Veteran contracted dengue fever in service which led to his heart problems and caused his death. In March 2017 letters, the Veteran's children stated that the Veteran endured shrapnel injuries from a bomb in service which led to him being discharged. In a June 2019 informal hearing presentation (IHP), the appellant's representative stated that the Veteran died of ischemic heart disease which was caused by his service-connected anxiety disorder. The appellant's representative expressed that the Veteran's anxiety disorder would best be characterized as posttraumatic stress disorder (PTSD) even though he was not diagnosed with PTSD during his lifetime. The appellant's representative then cited to treatise articles linking PTSD to coronary artery disease. The appellant's representative also noted that the Veteran was service-connected for hepatitis which could have caused his heart disease either directly or in combination with his service-connected anxiety disorder. Analysis First, the Board finds the Veteran's service-connected anxiety disorder was undiagnosed PTSD. A June 2021 VA examiner rendered an opinion. The examiner explained a review of the Veteran's service treat records (STRs) showed he was diagnosed with anxiety state secondary to combat experience in 1945. The examiner explained the condition was not then in the DSM and the diagnosis of PTSD did not exist until 1980. The examiner explained the Veteran was psychiatrically hospitalized twice during service. The first time for 40 days and the second time for over sixty days due to negative psychological reaction to combat. The examiner explained the Veteran was discharged from service with symptoms that would now be consistent with a diagnosis of PTSD. The symptoms included changes in appetite, excitability, hypervigilance, exaggerated startle response, irritability, and trouble sleeping. Additionally, the examiner noted the Veteran served 165 days in combat satisfying criterion A for the diagnosis of PTSD. The examiner concluded the Veteran suffered from undiagnosed PTSD at the time of separation from service. Accordingly, the appropriate diagnosis for the service-connected mental health condition would be PTSD. Second, the Veteran's service-connected PTSD was a contributory cause of death. The June 2021 VA examiner opined it was at least as likely as not that the Veteran's PTSD negatively impacted his psychical health. The examiner further found it plausible that the Veteran's PTSD contributed to the medical conditions that ultimately resulted in the Veteran's death. The examiner based these opinions on medical and psychological research. The examiner cited to the VA research submitted by the appellant's representative. The study concluded that PTSD was found to be associated with non-specific echocardiogram (ECG) abnormalities, atrioventricular conduction defects, and infarctions. The Board observes that a coronary occlusion is defined as a partial or total obstruction of the artery usually resulting in a myocardial infarction. A February 2020 VA examiner opined it was less likely than not service-connected anxiety and/or PTSD substantially or materially contributed to the Veteran's death. The examiner stated anxiety and PTSD are separate entities and medically unrelated to the Veteran's heart conditions and there was no objective evidence anxiety and PTSD substantially or materially contributed to the Veteran's death. However, as the Board determined in a May 2021 remand, the February 2020 VA examination report is inadequate because the examiner did not discuss the articles mentioned in the June 2019 informal hearing presentation (IHP). Moreover, the examiner did not address whether the Veteran suffered from undiagnosed PTSD. Lastly, the rationale is not complete. The February 2020 VA examiner did not explain why the mental health disorder and the heart conditions are unrelated. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that most of the probative value of an opinion comes from its rationale or underlying reasoning). Therefore, the February 2020 VA examiner's report is of lesser probative weight. The Board affords greater probative weight to the June 2021 VA opinion. First, the examiner thoroughly explains why the Veteran had undiagnosed PTSD based on his symptoms in-service and the diagnostic criteria. Second, the examiner explained how the medical research regarding PTSD was relevant in the Veteran's case. Lastly, the June 2021 VA examiner was a psychologist. The February 2020 VA examiner was an internal medicine physician. A psychologist is a specialist and the mental health field and more equipped to opine on the effects of a mental health condition. Accordingly, the Board finds the Veteran's service-connected anxiety was undiagnosed PTSD which was a contributory case of his death. Service connection for the Veteran's cause of death is warranted and the appellant's claim is granted. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Bruton, C 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.