Citation Nr: 21072582 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 13-09 022A DATE: December 3, 2021 ORDER An initial disability rating greater than 50 percent for acquired psychiatric disorder, to include anxiety disorder, insomnia disorder, and/or posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for a heart disorder, to include aortic valve stenosis, as secondary to a service-connected disability, is denied. Entitlement to service connection for hypertension as secondary to a service-connected disability is denied. FINDINGS OF FACT 1. Since the grant of service connection until his death, the Veteran's acquired psychiatric disorder, to include anxiety disorder, insomnia disorder, and/or PTSD was manifested by no more than occupational and social impairment with reduced reliability and productivity due to such symptoms such as: anxiety and mild memory loss, such as forgetting names, directions, or recent events. 2. There is no evidence of a heart disorder in service and no competent medical evidence linking the Veteran's heart disorder with his period of service, to include a service-connected disability. 3. There is no evidence of hypertension in service, or withing one year from his discharge from service, and no competent medical evidence linking the Veteran's hypertension with his period of service, to include a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating greater than 50 percent for acquired psychiatric disorder, to include anxiety disorder, insomnia disorder, and/or PTSD have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 9400. 2. The criteria for service connection for a heart disorder are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1952 to June 1954. The Veteran died in September 2014. Thereafter, the Veteran's widow requested to be substituted as the appellant for purposes of processing claims on appeal at the time of the Veteran's death. See 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010; see also 79 Fed. Reg. 52977-85 (Sept. 5, 2014). This request for substitution was granted in March 2015. This case comes to the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (VA) in Milwaukee, Wisconsin which, in part, denied granted service connection for an acquired psychiatric disorder, assigning a 50 percent disability rating effective October 18, 2010, and denied service connection for a heart disorder and hypertension. With regard to the characterization of the psychiatric issue on appeal, the Board notes that this disability was initially characterized as anxiety disorder, not otherwise specified. However, during the course of this appeal, the Veteran also perfected appeals regarding issues of entitlement to service connection for PTSD and insomnia. Notably, a March 2019 supplemental statement of the case recharacterized the anxiety disorder as acquired psychiatric disorder, to include anxiety disorder, insomnia disorder, and/or PTSD. As such, the insomnia and PTSD service connection issues are no longer on appeal. The above issues were previously before the Board in November 2016, February 2020, and August 2021 and, on each occasion, were remanded for additional development. 1. An initial disability rating greater than 50 percent for acquired psychiatric disorder, to include anxiety disorder, insomnia disorder, and/or PTSD, is denied. Prior to his death, the Veteran sought a higher initial rating for his service-connected psychiatric disorder. By way of history, the Veteran submitted an initial claim for service connection for a psychiatric disorder in March 2010 and, while the claim was initially denied, he submitted a subsequent claim in October 2010 and, by rating decision dated in July 2011, the RO granted service connection for anxiety disorder, assigning a 50 percent disability rating effective October 18, 2010. The Veteran disagreed with this decision and perfected this appeal. Subsequently, a March 2019 supplemental statement of the case recharacterized the anxiety disorder as acquired psychiatric disorder, to include anxiety disorder, insomnia disorder, and/or PTSD. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a "staged" rating are required. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The Court since has extended this practice even to established ratings, not just initial ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran's psychiatric disorder is currently rated under DC 9400 as 50 percent disabling. Pursuant to DC 9400, a 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.71a, DC 9400, General Rating Formula for Mental Disorders. Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. In addition, the rating must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Further, when rating the level of disability from a mental disorder, the extent of social impairment is considered, but a rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126. Evidence relevant to the current level of severity of the Veteran's psychiatric disorder prior to his death includes VA psychiatric examination reports dated in May 2010, June 2011, and June 2014 as well as VA medical opinions following his death dated in October 2017 and November 2020. During the May 2010 VA examination, it was noted that the Veteran had been treated for anxiety through VA since October 2002 and was previously found to experience Benzodiazepine dependence. He reportedly had treated his anxiety with medication for over 30 years and denied individual psychotherapy. On psychiatric examination, the Veteran was clean and both his psychomotor activity and speech were unremarkable. The Veteran was cooperative and attentive, his affect was appropriate, and his mood was good. With regard to attention, the Veteran was unable to perform serial 7's but could spell a word forward and backward. He was oriented to person, time, and place. Thought process and content were unremarkable, and there were no delusions. With regard to judgment, the Veteran understood the outcome of his behavior and his intelligence was average. Regarding insight, the Veteran partially understood that he had a problem. There was no sleep impairment and there were no hallucinations or inappropriate behaviors. The Veteran interpreted proverbs appropriately and there was no obsessive/ritualistic behavior. The Veteran denied experiencing panic attacks and or homicidal/suicidal thoughts. Impulse control was good and there were no episodes of violence. The Veteran was able to maintain minimum personal hygiene and there were no problems with activities of daily living. Remote/recent memory were normal, but his immediate memory was moderately impaired. Regarding mental competency, the Veteran was able to manage his financial affairs. The Veteran last worked as a library assistant at a public elementary school in December 2009 and quit working due to problems with his legs. The examiner diagnosed anxiety disorder by history as well as sedative/hypnotic or anxiolytic dependence. During the June 2011 VA examination, the Veteran reiterated his history of psychiatric care for anxiety since 1992. The Veteran reported a history of daily tension, insecurity, and memory problems. He also experienced intense nightmares about twice per week. He reported being abstinent from alcohol for more than 20 years and denied both nicotine and illicit drug use. The Veteran lived with his wife of 50 plus years and described their relationship as "good." He also had three grown daughters. On psychiatric examination, the Veteran was clean, appropriately dressed, and both his psychomotor activity and speech were unremarkable. The Veteran was cooperative and attentive, his affect was appropriate, and his mood was dysphoric. With regard to attention, the Veteran was unable to perform serial 7's but could spell a work forward and backward. He was oriented to person, time, and place. Thought process/content were unremarkable and there were no delusions. With regard to judgment, the Veteran understood the outcome of his behavior and his intelligence was average. Regarding insight, the Veteran partially understood that he had a problem. There was sleep impairment but there were no hallucinations or inappropriate behaviors. The Veteran interpreted proverbs appropriately and there was no obsessive or ritualistic behavior. The Veteran denied experiencing panic attacks and or homicidal or suicidal thoughts. Impulse control was good and there were no episodes of violence. The Veteran was able to maintain minimum personal hygiene but there were some problems with activities of daily living, specifically moderate difficulty with household chores, shopping, engaging in sports/exercise, and driving as well as the prevention of driving. Memory was reportedly normal. Regarding mental competency, the Veteran was unable to manage his financial affairs. It was reiterated that the Veteran last worked as a library assistant at a public elementary school in December 2009 and quit working due to problems with his legs. The examiner diagnosed anxiety disorder, not otherwise specified as well as Benzodiazepines (sedative/hypnotic or anxiolytic) dependence. During the June 2014 VA examination, the examiner continued a diagnosis of anxiety disorder, unspecified and found that the Veteran's psychiatric disability resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by medication. The Veteran continued to be married to his wife of over 50 years and continued to be unemployed, last working as a library at an elementary school due to leg problems. The examiner noted that the Veteran's psychiatric disability resulted in anxiety as well as mild memory loss, such as forgetting names, directions, or recent events. As noted above, the Veteran died in September 2014. This issue was remanded for additional development in November 2016. Significantly, the remand noted that the June 2014 VA examination report shows that the Veteran's psychiatric symptoms were limited to anxiety and mild memory loss prior to his death. However, in an April 2013 statement, the Veteran reported several other psychiatric symptoms, including nightmares, flashbacks, hypervigilance, prolonged periods of depression, feelings of worthlessness, constant dysphoria and anhedonia, isolation, frustration, mood changes, irritable outbursts, a dislike of loud noises, impaired judgment, and disorientation, particularly in crowds. Because the June 2014 examination report did not reflect consideration of this lay statement, this issue was remanded for an additional VA medical opinion to determine the nature and severity of the Veteran's psychiatric disability during the period on appeal. Pursuant to the November 2016 Board remand, such opinion was obtained in October 2017. First, the October 2017 VA examiner noted that the Veteran's psychiatric diagnoses from March 2010 to his death in September 2014 were limited to anxiety disorder, unspecified and Sedative/Hypnotic or Anxiolytic Dependence. Second, regarding the impact of the Veteran's service-connected anxiety on his occupational and social functioning, including the impact it had on his activities of daily living and the overall functional impact, the Veteran was having memory difficulties that, in the examiner's opinion (as per the May 2010 VA examination) were caused or secondary to long term use of benzodiazepines, sedative/hypnotic/anxiolytic medications. However, being dependent on these medications convey physical as well as mental disabilities by themselves since they can cause memory difficulties as well as unsteadiness, dizziness with increased risk for falls. Three, insomnia was an inherent part of the Veteran's anxiety disorder symptomatology. And, four, the Veteran's anxiety disorder has been found to be caused or secondary to active-duty stressors. As above, this issue was remanded for again in February 2020. Significantly, the remand noted that the October 2017 VA examiner did not provide sufficient rationale as to whether a separately diagnosed disorder is either related to military service, or secondary to service-connected disability, or is part of the service-connected pathology. As such the case was remanded for additional medical opinion concerning whether a separately diagnosed psychiatric disability is related to the Veteran's military service. It was also requested that such opinion provide additional discussion as to the Veteran's reported symptoms so that the nature and severity of the Veteran's psychiatric disorder prior to his death can be accurately determined. Pursuant to the February 2020 Board remand, such opinion was obtained in October 2017. Significantly, the examiner noted that the Veteran's only diagnosed psychiatric disabilities during the appeal period was anxiety disorder, unspecified (including insomnia) and found that a PTSD diagnosis was not warranted. The examiner also found that the Veteran's psychiatric disability resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The examiner also found that, prior to the Veteran's death, his psychiatric symptoms were limited to anxiety as well as mild memory loss, such as forgetting names, directions, or recent events. Also of record are VA and private treatment records dated through September 2014. These records show findings similar to those noted in the above VA psychiatric examination reports. Based on these findings, the Board finds that the evidence of record does not substantiate an initial evaluation greater than 50 percent. Significantly, the evidence does not demonstrate that the Veteran's service-connected psychiatric disability is productive of occupational and social impairment with deficiencies in most areas or an inability to establish and maintain effective relationships. The evidence of record shows that, prior to his death, the Veteran maintained a good relationship with his wife of over 50 years and three grown daughters. While the Veteran retired from employment in December 2009, this was due to physical disability, not mental disability. Overall, the totality of the evidence reflects symptoms warranting no more than a 50 percent rating under the applicable criteria. Prior to his death, there was no evidence of such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene, or other symptoms on par with the level of severity contemplated by these symptoms in the higher rating criteria. Rather, his symptoms were more in line with those at the 50 percent level namely anxiety and mild memory loss. In sum, the Board concludes that, prior to his death, the Veteran's service-connected psychiatric disability was not manifested by symptomatology that nearly approximated the criteria for the next higher evaluation under DC 9400. SERVICE CONNECTION Service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities such as hypertension are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303 (b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for a heart disorder, to include aortic valve stenosis, is denied. 2. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability, is denied. Prior to his death, the Veteran sought service connection for a heart disorder, to include aortic valve stenosis, and/or hypertension. Specifically, he contended that such are secondary to his service-connected psychiatric disability. The Veteran's service treatment records are negative for specific complaints regarding the heart or cardiovascular system. The Veteran's January 1954 separation examination shows a normal heart and show a blood pressure reading of 120/70, which is in the normal range. Post-service treatment records show a diagnosis of arterial hypertension as early as July 1987 and a diagnosis of aortic valve stenosis as early as March 2005. Notably, in a November 1992 VA psychiatric examination, the Veteran reported that his anxiety elevates his blood pressure. The Veteran submitted an initial claim for service connection for a heart disorder in October 2010. While the Veteran was never afforded a VA heart examination during his lifetime, pursuant to the November 2016 Board remand, a medical opinion was obtained in October 2017. The October 2017 VA examiner noted a diagnosis of hypertension as early as 1985 and opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. As rationale for this opinion, the examiner noted that the claims file and VA electronic medical record were silent for a diagnosis and/or treatment for either hypertension or a heart condition during active-duty service. As this opinion only addressed direct service connection, an addendum medical opinion was obtained in February 2019. The February 2019 VA examiner opined that there was no evidence of worsening of hypertension due to a mental condition such that would support secondary service connection. As noted above, this issue was remanded again in February 2020. The remand noted that the October 2017 and February 2019 VA opinions provided insufficient rationale and conflicting information and remanded the claim once more for a medical opinion regarding the nature and etiology of the claimed conditions. Pursuant to the February 2020 Board remand, an additional medical opinion was obtained in April 2021. The April 2021 VA examiner opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of a service-connected disability. As rationale for this opinion, the examiner noted that aortic valve stenosis and anxiety disorder, not otherwise specified including insomnia are different disease entities with different pathophysiological process unrelated to each other. Similarly, the examiner noted that aortic valve stenosis and the Veteran's service-connected lumbar spine disability (lumbar spondylosis; minimal annular bulge at l1-l2 and l2 l3; mild posterolisthesis of l3 over l4) are different disease entities with different pathophysiological process unrelated to each other. As above, this issue was remanded again in August 2021. Significantly, the remand noted that the April 2021 opinion addresses a heart disorder but not hypertension. Further, the opinion regarding the heart is not explained in detail. Pursuant to the August 2021 Board remand, an additional medical opinion was obtained in April 2021. With regard to direct service connection, the examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Regarding the claimed heart disorder, the examiner noted that a review of the claims file is negative for chronicity of care, complaints and/or treatment related to aortic valve stenosis during his active duty service or within a year of separation. Significantly, the Veteran's January 1954 separation examination is negative for a heart condition. Regarding the claimed hypertension, the examiner noted that a review of the claims file is negative for evidence of recurrent, persistent, consecutive, nor sustained elevated blood pressures to support a diagnosis of hypertension during active-duty period. Furthermore, the claims filed is negative for chronicity of care, complaints and/or treatment related to hypertension during his active-duty service or within a year. The Veteran's January 1954 separation examination is negative for hypertension. With regard to secondary service connection, the examiner also opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of a service-connected condition. As rationale for this opinion, it was noted aortic valve stenosis and lumbar spondylosis are different disease entities with different pathophysiological process unrelated to each other, that can co-exist together. There is no evidence in the medical literature that links lumbar condition as an etiology of now claimed aortic valve stenosis. Similarly, aortic valve stenosis and anxiety disorder, not otherwise specified including insomnia are different disease entities with different pathophysiological process unrelated to each other that can co-exist together. There is no evidence in the medical literature that links anxiety disorder as an etiology of now claimed aortic valve stenosis. With regard to aggravation of the heart disorder, the examiner further opined that the Veteran's aortic valve stenosis/heart condition was less likely than not aggravated beyond its natural progression by the Veteran's lumbar spine disability as there is no objective evidence that the Veteran's aortic valve stenosis has been aggravated beyond its natural progression by his service-connected lumbar spine disability and these disabilities encompass different disease entities with different pathophysiological process unrelated to each other, that can exist together. These are different disease entities and would not expect any aggravation. The examiner further opined that aortic valve stenosis was less likely than not aggravated beyond its natural progression by the Veteran's anxiety disorder as there is no objective evidence that the Veteran's aortic valve stenosis has been aggravated beyond its natural progression by his service-connected anxiety disorder and these disabilities encompass different disease entities with different pathophysiological process unrelated to each other, that can exist together. These are different disease entities and would not expect any aggravation. With regard to aggravation of the hypertension, the examiner further opined that hypertension was less likely than not aggravated beyond its natural progression by the Veteran's lumbar spine disability as there is no objective evidence that the Veteran's hypertension has been aggravated beyond its natural progression by his service-connected lumbar spine disability as they are different disease entities with different pathophysiological process unrelated to each other, that can exist together. These are different disease entities and would not expect any aggravation. The examiner further opined that the Veteran's hypertension was less likely than not aggravated beyond its natural progression by the Veteran's anxiety disorder as there is no objective evidence that the Veteran's hypertension has been aggravated beyond its natural progression by his service-connected anxiety disorder and these disabilities encompass different disease entities with different pathophysiological process unrelated to each other, that can exist together. These are different disease entities and would not expect any aggravation. Upon review of the above evidence, the Board finds that service connection for either a heart disorder or hypertension is not warranted. With regard to presumptive service connection, while hypertension is classified as a "chronic disease" under 38 C.F.R. § 3.309(a), there is no indication of hypertension within one year of the Veteran's discharge from military service. As above, the Veteran was not actually diagnosed with hypertension until July 1987, approximately 33 years after his discharge from military service. Furthermore, aortic valve stenosis is not a "chronic disease" under 38 C.F.R. § 3.309(a). As such, presumptive service connection on the basis of continuity of symptomatology is not warranted for the Veteran's hypertension. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. The claims are also denied on a direct basis. The Veteran's service treatment records are negative for heart problems and post-service treatment records are negative for hypertension until July 1987 and are negative for aortic valve stenosis until March 2005, approximately 33 years and 51 years after his discharge from service. Such a lapse of time is a factor for consideration in deciding a service connection claim. Maxson v. Gober, 230 F.3rd 1330, 1333 (Fed. Cir. 2000). Also, there is no medical evidence in the record that links the Veteran's current heart disorder or hypertension to an incident of the Veteran's active military service. Significantly, there have been no allegations of continuity of symptomatology with regard to the Veteran's heart disorder/hypertension. The claims are further denied on a secondary basis. While the November 1992 VA psychiatric examination suggests a possible relationship between the Veteran's anxiety and elevated blood pressure, as above, the October 2017, February 2019, April 2021, and October 2021 VA examiners each found that the Veteran's heart disorder/hypertension are not related to the Veteran's service-connected lumbar spine and/or psychiatric disabilities. The rationale the most recent opinions in October 2021 was, essentially, that there is no physical nor temporal relationship between these disabilities. There are no contrary medical opinions of record. While the Veteran, prior to his death, alleged that his heart disorder and hypertension are related to his military service, the Board finds that the question regarding the potential relationship between the Veteran's heart disorder and hypertension, and any instance of his military service, to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (providing that although a veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, a veteran is not competent to provide evidence as to more complex medical questions). Furthermore, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). In this regard, the question of causation of the Veteran's heart disorder and hypertension involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. Accordingly, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection for a heart disorder and/or hypertension. As the evidence is not in relative equipoise, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. C. Casey Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board April Maddox, 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.