Citation Nr: 21070281 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 17-28 583A DATE: November 23, 2021 ORDER Entitlement to service connection for headaches is granted. Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to an evaluation of 10 percent for multiple, noncompensable, service-connected disabilities pursuant to 38 C.F.R. § 3.324 is denied. FINDINGS OF FACT 1. The Veteran has a headaches disability that is, as likely as not, causally related to the Veteran's active service. 2. The preponderance of evidence shows that the Veteran's left shoulder disability was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 3. The preponderance of evidence shows that the Veteran's right shoulder disability was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 4. The Veteran is currently in receipt of a 70 percent rating for posttraumatic stress disorder (PTSD), a 50 percent rating for sleep apnea, and two noncompensable ratings for tinea pedis and hypertension, for a combined total rating of 90 percent. CONCLUSIONS OF LAW 1. The criteria for service connection for a headaches disability have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1118, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2021). 2. The criteria for entitlement to service connection for a left shoulder disability have not been met or approximated. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2021). 3. The criteria for entitlement to service connection for a right shoulder disability have not been met or approximated. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2021). 4. The criteria for entitlement to a 10 percent evaluation under 38 C.F.R. § 3.324 based on multiple noncompensable service-connected disabilities have not been met. 38 U.S.C. §§ 501, 5107 (2012); 38 C.F.R. § 3.324 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1984 to January 1998, and again from April 1998 to June 2004. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA) in Cleveland, Ohio. The Board remanded the issue on appeal for additional development in April 2019. The directives having been substantially complied with, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). This appeal was originally certified to the Board with two additional issues: entitlement to service connection for an acquired psychiatric disorder, and entitlement to service connection for sleep apnea. However, in an April 2020 rating decision, the RO granted entitlement to service connection for an acquired psychiatric disorder, diagnosed and rated as PTSD, and also for sleep apnea. As such, the issues are no longer in appellate status before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). While the Veteran is currently unrepresented, the Board notes the previous representative, attorney J.M.W., submitted written correspondence to the Board received on February 10, 2021 indicating the Veteran had contacted that previous representative indicating he no longer wished to be represented by that attorney, J.M.W. While the Veteran himself did not so directly state as such to the Board or any other office of the VA, that attorney sent correspondence to the Board seeking to withdraw pursuant to 38 C.F.R. § 20.6 (2021) (previously 38 C.F.R. § 20.608 in 2018 and prior) because of factors which make the continuation of representation impossible, impractical, or unethical. The Board noted that withdrawal request occurred after the original certification to the Board of this legacy appeal on February 3, 2018. A Board Deputy Vice Chairman reviewed this withdrawal request and on October 14, 2021, notified the previous representative, attorney J.M.W., that the withdrawal request was approved. As the Veteran is now unrepresented in this case, VA has a duty to construe his claims liberally. See Moody v. Principi, 360 F.3d 1306, 1310 (Fed. Cir. 2004); Szemraj v. Principi, 357 F.3d 1370, 1373 (Fed. Cir. 2004). Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2021). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert. denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection General Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence 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-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include arthritis, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For arthritis, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). Service connection can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). For a chronic disease to be considered to have been "shown in service," there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. In making that decision, the Board must determine the probative weight to be ascribed as among multiple medical opinions, and state the reasons and bases for favoring one opinion over another. See Winsett v. West, 11 Vet. App. 420, 424-25 (1998); see also Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). This responsibility is particularly important where medical opinions diverge. The Board is also mindful that it cannot make its own independent medical determinations, and that there must be plausible reasons for favoring one medical opinion over another. See Evans at 31; see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Evidence and Analysis - Headaches The Veteran asserts that his diagnosed headaches disability is due to his service, to include from multiple sources, include motor vehicle accidents that occurred during active service, and also a helicopter accident where he was a passenger in a military helicopter that endured a hard landing. He asserted in his original claim in August 2007 that his headaches began approximately 1991 in his first term of service. The Veteran received a VA examination for his headaches in March 2008. Here, the Veteran noted he first started getting regular headaches when he was stationed in Korea in 1991, after his return from Operation Desert Storm. He described the frequency as about twice a month, and that he experienced mild photophobia and phonophobia. The examiner noted a history of headaches going back to April 1984 when he had a respiratory illness and noted the Veteran's cranial nerves were intact and neurological examination was otherwise unremarkable. An explicit opinion for service connection was not provided, though the VA examiner thought it unlikely there was a chronic disability of headaches relating back to active service, saying only that the Veteran's diagnosed headaches were not likely associated with his hypertension or its medication. The Veteran received another examination for his headaches in July 2015, this time from a private physician, Dr. H.S. This physician noted a diagnosis of tension headaches and cited the first evidence of such in the Veteran's service treatment records from 1997. The Veteran stated in this this examination that his headaches have grown more severe and also were more frequent in recent years. Symptoms were described as pulsating or throbbing head pain, with pain on both sides of the head. During a headache episode, nausea, vomiting, sensitivity to light, sensitivity to sound, and changes in vision were noted. Prostrating headaches characteristic of migraines were not noted. This examiner provided a positive opinion for direct service connection, saying it was as likely as not, greater than 50 percent probability, that the Veteran's currently diagnosed headaches relate back to active service. The examiner's opinion was based on the starting period for the diagnosed headaches well back into the Veteran's active service and that the headaches have continued into the present day. The Veteran received another VA examination for his headaches in September 2019. This examiner diagnosed a migraine headaches condition, noting an onset back in the mid-1980s during the Veteran's active service. The VA examiner noted the Veteran's headaches increased in frequency following his motor vehicle accident in 1987. The Veteran's motorcycle accident in 2003 was also noted. This examiner also noted that a tumor in the Veteran's skull had been found and diagnosed in early 2018, and that tumor could be a source for the Veteran's headaches. This examiner provided a negative opinion for service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran's claimed condition was incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale was that the Veteran has a history of traumatic brain injury and that his memory makes it difficult for him to recall dates and when things happened. The examiner noted the tumor found on imaging in 2017 is slow growing, is not cancerous, but that it could cause headaches, especially as the tumor grows. 1. Entitlement to service connection for headaches The Board notes the mix of opinion but finds the VA examiner's April 2008 and September 2019 examinations and opinions for service connection to be of lower probative value. While the examinations themselves were satisfactory, neither the April 2008 or September 2019 VA examiners who conducted the actual examination indicated they responded to the Veteran's statements regarding his own history. While the Board notes case law that an examiner need not review the claims file to include pertinent statements prior to providing as opinion, it does require that the examiner is aware of all pertinent facts from the Veteran's history. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (Vet. App. 2008). Furthermore, and critical to this case, the Veteran has a complex set of medical diagnoses, to include other psychiatric and neurological maladies that may relate to the Veteran's headaches. Other VA examiners in different appeal streams discussed the headache conditions and their relatedness to other body systems, some of which are already service connected. Here, neither the April 2008 and September 2019VA examiners did that, indicating perhaps a limited purview of medical records beyond those that pertained only to the Veteran's headaches. The Board finds here that the Veteran's statements of his incidents in service were discounted, the resulting opinions by the different examiners were conclusory, and thus considers the probative value of this opinion to be low because of that. Additionally, even though the April 2008 examiner notes the claims file had been reviewed, he did not note the earlier private treatment records regarding the headaches or possible contributing injuries, such as the multiple motor vehicle accidents. The Board notes both the April 2008 and September 2019 examiners' opinion relied only on an observed lack of evidence to determine that there was no nexus of the diagnosed headaches conditions back to active service. The September 2019 examiner noted the Veteran's complaints and history and stated he found no reason to doubt the Veteran's statements, but still noted a negative opinion for service connection based solely on the lack of records after service. A VA opinion is inadequate where a VA examiner ignores the Veteran's lay statements of an injury/event during service unless the Board expressly finds that no such injury/event occurred. Dalton v. Nicholson, 21 Vet. App. 23 (2007). In order for the Board to rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence; the Board should ensure any such finding was well supported by the facts and data and reflects that the examiner has considered "all procurable and assembled data," by obtaining all tests and records that might reasonably illuminate the medical analysis. Jones v. Shinseki, 23 Vet. App. 382 (2010). In contrast, the Board gives substantial probative weight to the Veteran's private physician, Dr. H.S., who considered the Veteran's headaches disability to be more likely than not related to his active service. Dr. H.S.'s statement, made in July 2015, recounted the diagnosis and history with the Veteran's headache problems. This physician's positive opinion for direct service connection was based on his own medical examinations of the Veteran and medical history from service, to include the service treatment records. This physician also had access to the Veteran's VA medical examinations and opinions, and in his opinion of July 2015, pointed out the differences between his own opinion regarding etiology, using positively observed medical evidence, vice the mere absence of information used by the VA examiners in their negative opinions. Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Board finds the lay statements of the Veteran to be highly credible and probative. Importantly, there is no reason to doubt the credibility of the Veteran's self-reported history of his service headache conditions. The Board notes especially the detailed consistency of the Veteran's statements regarding his headache complaints and treatment experiences over time. See 38 C.F.R. § 3.159(a)(2) (lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person); see Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Smith v. Derwinski, 1 Vet. App. 235, 237-38 (1991) (credibility determinations are within the purview of the Board). See also 38 U.S.C. § 1154(a) (reflecting that due consideration is to be given to the places, types, and circumstances of a claimant's service). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board also notes the more recent precedential case of Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), where the Federal Circuit held that pain alone can qualify as a disability for VA purposes if it amounts to a functional impairment of earning capacity. Id. at 1367-68. The Board certainly acknowledges that the latter April 2018 Saunders decision came out after the rating decision on appeal from February 2015, but the Board notes that both the April 2008 and September 2019VA examiners had documented in their examinations and opinions the functional impacts of the Veteran's headaches complaints and the continuing negative impact on the Veteran's activities of daily living. In Saunders, the Federal Circuit noted 38 C.F.R. § 4.10 defines functional impairment as the inability of the body or a part of it "to function under the ordinary conditions of daily life including employment" and found that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability." Saunders, 886 F.3d at 1363. In other words, "pain alone can serve as a functional impairment and therefore qualify as a disability," even if there is no identified underlying diagnosis. Id. at 1367. Here, VA and private physicians have diagnosed the Veteran's headache disabilities, and thus the Board considers the precedential holding of Saunders to be pertinent and supportive of this Board decision. The Board finds evidence of a current disability of a headaches condition, as shown by recent VA and private treatment records as noted earlier in this decision. Thus, the first element of service connection is established. The second requirement is to establish in-service incurrence or aggravation of a disease or injury. Here, the claims file contains documentation of the Veteran's headaches conditions through lay statements of the Veteran and his service treatment records, plus a highly credible and probative statement from treating physician Dr. H.S. who knew the Veteran and provided a comprehensive positive opinion for service connection. For service connection claims, lay or medical evidence can establish an in-service injury or disease or chronicity of symptoms in service. A current disability and nexus to service is generally established by medical evidence. However, the Federal Circuit has held that lay evidence is sufficient to show certain current disabilities. Although medical evidence is generally necessary for a nexus to service, lay evidence can be sufficient to show continuity of symptoms after service, as a foundation for a nexus opinion, or to link chronic in-service symptoms to the same diagnosed current disability, or as a substitute for a nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). Additionally, the Board notes the guidance of the Federal Circuit with regard to lay evidence and proof of a claim for service connection, that examiners and adjudicators are required to address whether lay statements present sufficient evidence of the etiology of a claimant's condition such that his claim of service connection could be proven without contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336 fn. 1 (Fed. Cir. 2006). The Board notes the greater weight of the July 2015 opinion from his private physician, Dr. H.S., in favor of service connection over the April 2008 and September 2019 VA examiners' negative conclusory opinions regarding possible nexus. Also, a lay person is competent to report observable symptomatology of an injury or illness. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). Here, the Board finds the Veteran's statements as to the continuity of his symptoms in and since service regarding his headaches disability to be highly credible, and thus a continuity of symptoms since service satisfactory establishes the nexus requirement for service connection. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Thus, resolving any doubt in favor of the Veteran, the Board finds that his headaches condition is related to service. As such, service connection for a headaches disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Evidence and Analysis Left and Right Shoulder Disabilities The Veteran originally claimed in June 2014 that he had pain both shoulders since service. Service treatment records from November 2002 show that the Veteran complained of pain both shoulders, but upon his retirement from active service in June 2004, his separation physical examination did not indicate any complaints or problems with either shoulder. Those service records also indicate the Veteran was involved in a motorcycle accident in August 2003, but again, there was no indication of a chronic condition at the time of the separation physical examination in June 2004. The Veteran received a VA examination for his bilateral shoulders in September 2019. Each shoulder received three diagnoses: glenohumeral joint arthritis, AC joint arthritis, and degenerative arthritis. Flareups were noted for each shoulder, several times a day, when the Veteran attempted to raise an arm above the level of that shoulder, which would raise the pain level to about 8 on a scale of 10 while the arm was in its elevated position. The Veteran reported his left shoulder problems began while in service due to sports activities such as rock climbing and repelling, along with ruck marches with full gear. The Veteran noted the motorcycle accident of August 2003 and that he was treated for scrape wounds. This examiner provided a negative opinion for service connection for each shoulder, saying it was less likely than not, less than 50 percent probability, that the claimed shoulder condition for each the right and the left was incurred in or due to service. The examiner's rationale was that while the service records indicate a shoulder complaint in 2002, and the scrape wounds from the August 2003 motorcycle accident, the Veteran's retirement physical examination of June 2004 was silent for any shoulder complaints on either side. The examiner also noted that the Veteran's initial claim with VA in August 2007, three years after service, did not mention any shoulder condition or disability. The examiner pointed out that the initial diagnoses of osteoarthritis in each shoulder first occurred in 2014, ten years after leaving active service. 2. Entitlement to service connection for a left shoulder disability 3. Entitlement to service connection for a right shoulder disability The Board finds the September 2019 VA examination report and opinion to be of great probative value, along with both the VA treatment notes and private treatment regarding the Veteran's claimed shoulder disabilities. Indeed, the VA examiners considered the Veteran's contention, the claims file, and clinical medical evidence before providing a negative opinion for direct service connection. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiner's negative opinion was supported by a sufficiently clear and well-reasoned medical rationale and was consistent with the verifiable facts regarding the Veteran's contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The Board acknowledges that the Veteran is competent to testify as to his beliefs that his disabilities are related to service. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). In order for lay evidence to be competent, the individual must have personal knowledge, derived from his/her own senses, of what is being attested; "[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of his personal knowledge." Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the Veteran, via the supplied statements, is competent to testify about his symptoms relating to his claimed bilateral shoulder symptoms. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding etiology of his left or right shoulder disabilities. See 38 C.F.R. § 3.159(a)(1) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the etiology of any current condition, as the causative factors for such are not readily subject to lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. The Board acknowledges the Veteran's statements that his left and right shoulder symptoms could be related to service. However, the Board notes that the Veteran's service treatment records, to include reports of medical history, are silent for any treatment or complaint of any shoulder condition during active service ending in June 2004 beyond the scrape injuries of the motorcycle accident of August 2003, or until June 2014, the initial claim, ten years after active service ended. The Board notes especially that even though the Veteran asserts an August 2003 motorcycle accident was the cause of his bilateral shoulder conditions, that the service treatment records were silent for any chronic effects of that accident, to include any shoulder problems at the end of active service in June 2004. A negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board notes there are no statements by any medical provider, VA or private, that are in favor of a possible nexus to service for the Veteran's claimed left and right shoulder disabilities. Upon review of the record, the Board concludes that entitlement to service connection for a left shoulder or right shoulder disability is not warranted. The Board notes a current diagnosis of a left shoulder and right shoulder disability in September 2019, and thus the requirement for a current disability is shown for each the left shoulder and right shoulder claims. The Board acknowledges the Veteran's contentions, and the Veteran's post-service statements are noted. However, the Veteran's service medical records, to include all examinations, are silent for any existing shoulder condition at the time of separation, left or right, and there is no competent evidence to tie the current assertions to any in-service disease or injury. A VA examiner has discussed all of the Veteran's shoulder disabilities and all possible risk factors raised by the record, and opined that the current left or right shoulder disabilities are not related back to active service. The Board thus finds the Veteran fails the third prong of the test for entitlement to direct service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. With regard to possible presumptive service connection for degenerative arthritis, the weight of evidence shows no formal diagnosis of any shoulder arthritis, left or right, on any examination, private or VA, until September 2019, 15 years after active service. As such, presumptive service connection is not warranted. 38 C.F.R. §§ 3.303, 3.309. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed left and/or right shoulder disabilities were not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a left shoulder or right shoulder disability, and the claims must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to an evaluation of 10 percent for multiple, noncompensable, service-connected disabilities pursuant to 38 C.F.R. § 3.324 The Veteran claimed back in June 2014 at the time of his original claim in this appeal for an evaluation of 10 percent for his multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324. At the time of that original claim, the Veteran had two noncompensable service-connected disabilities for tinea pedis and for hypertension, and no others. The Board notes the language of 38 C.F.R. § 3.324: "[w]henever a veteran is suffering from two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the 1945 Schedule for Rating Disabilities, the rating agency is authorized to apply a 10-percent rating, but not in combination with any other rating." At the time of the original claim, the Veteran was service-connected only for the two noncompensable disabilities noted above. Since that time, the Veteran is also service-connected for posttraumatic stress disorder with a 70 percent evaluation, and sleep apnea with a 50 percent evaluation. In addition, the Veteran has a claim for a total disability evaluation based on individual unemployability being evaluated by the RO and not before the Board at the time of this decision. The Board notes the language: " . . . not in combination with any other rating." 38 C.F.R. § 3.324. Since the time of the original claim, the Veteran has been awarded compensable ratings for two other disabilities besides the tinea pedis and the hypertension, and now has a 90 percent total combined evaluation, even prior to this Board decision. Because the Veteran is already in receipt of compensable evaluations at the time of this Board decision, the provisions of 38 C.F.R. § 3.324 are not applicable in his case. Accordingly, the claim for compensation pursuant to the provisions of 38 C.F.R. § 3.324 must be denied as a matter of law. Where the law is dispositive, the claim must be denied on the basis of absence of legal merit. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Setter, 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.