Citation Nr: 21074088 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 10-02 836 DATE: December 14, 2021 REMANDED Entitlement to service connection for the cause of the Veteran' death is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1966 to January 1968. Unfortunately, he died in August 2005. The appellant is his surviving spouse, so widow. She appealed to this Board of Veterans' Appeals (Board) from a January 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This claim was denied by the Board in a December 2017 decision and, in response, the Appellant-widow appealed to the U. S. Court of Appeals for Veterans Claims (Veterans Court/CAVC). In an October 2019 Memorandum Decision, the Court vacated the Board's decision denying this claim and remanded it back to the Board for further development and readjudication in compliance with directives specified. In October 2020, the Board in turn remanded this claim back to the RO, so back to the Agency of Original Jurisdiction (AOJ). Unfortunately, there was not the required compliance, even acceptable substantial compliance, with the Board's prior remand directives, meaning the Board must again remand this claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran [or here, appellant], 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). Entitlement to service connection for the cause of the Veteran's death is again remanded. The prior October 2020 Board remand directed that VA obtain outstanding service treatment records (STRs) and an addendum opinion addressing whether the Veteran's disorders that caused or contributed substantially or materially to his death onset during or were related to his service. To this end, the examiner was asked to specifically address the contention that the Veteran had received a blood transfusion during his service and what, if any, impact that blood transfusion had or would have had on his thrombotic thrombocytopenic purpura (TTP) or hemolytic-uremic syndrome (HUS) disorder and cause of death. In September 2021, after the outstanding STRs had been obtained and associated with the claims file, a VA examiner reviewed the file and provided an addendum opinion. However, a review of the opinion reveals the examiner only stated that the STRs did not show the Veteran received a blood transfusion while in service, so the examiner did not address the assertion that he did and what impact, if any, it might have had on his eventual death. Additionally, the September 2021 VA examiner did not provide adequate rationale as to why the Veteran's TTP/HUS were not directly (instead of presumptively) caused by his presumed exposure to the dioxin in herbicide agents, to include Agent Orange. Rather, the examiner simply stated that TTP/HUS is not included in the conditions presumptively associated with exposure to herbicide agents. However, in this circumstance this does not absolve the examiner of still commenting on whether there is a direct correlation between eventual disability (or, here, death) and the presumed exposure to the dioxin in Agent Orange. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); see also McCartt v. West, 12 Vet. App. 164, 167 (1999) (indicating the principles set forth in Combee, which, instead, concerned exposure to radiation, are equally applicable in cases involving Agent Orange exposure to establish direct causation). Thus, these failings must be corrected before readjudicating this claim. Accordingly, this claim is again REMANDED for the following still additional development and consideration: 1. Obtain still more medical comment (another addendum opinion) from a qualified VA examiner. The examiner is asked to address the following: Is it at least as likely as not (50 percent probability or greater) that the disorders that caused or contributed substantially or materially to the Veteran's death (including especially arrhythmia, hyperkalemia, and renal failure) onset during his military service from January 1966 to January 1968 or are otherwise related or attributable to his service, including to his presumed exposure to herbicides in Vietnam? *The examiner is advised that an unfavorable opinion cannot be based solely on the fact that the Veteran's causes of death including TTP/HUS, are not on the list of diseases that are presumptively associated with exposure to herbicide agents. Rather, even accepting that as true, the examiner still must address the additional possibility of direct service connection, meaning of a direct correlation ("nexus") between the Veteran's presumed exposure to herbicides during his service and eventual death. *To this end, the examiner must specifically address the contention that the Veteran received a blood transfusion during his service in terms of what, if any, impact that had or would have had on his TTP/HUS and eventual death. If, as the prior September 2021 VA examiner concluded, there is no mention of a blood transfusion in the Veteran's STRs, please also provide more explanation of why it is reasonable to have expectation of documentation of this type of procedure in the STRs, so aside from commenting on whether there is any correlation between that purported procedure in service and the conditions that eventually caused or contributed substantially or materially to the Veteran's death. Rationale for the opinion thus is essential, regardless of whether favorable or unfavorable to the claim, preferably citing to evidence in the file supporting conclusions and/or accepted medical authority. 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.