Citation Nr: 21075271 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 15-40 562 DATE: December 20, 2021 ORDER Entitlement to accrued benefits is dismissed. Entitlement to service connection for cause of death is granted. FINDINGS OF FACT 1. The agency of original jurisdiction (AOJ) has not made an initial determination as to whether the Veteran's surviving spouse may be considered an eligible substitute. 2. The Veteran died in November 2012; the death certificate lists cardiopulmonary arrest and cerebrovascular accident as the cause of death. 3. At the time of death, the Veteran was service connected for posttraumatic stress disorder (PTSD), tinnitus, malaria and bilateral hearing loss. 4. The Veteran's service-connected PTSD aided or lent assistance in causing death. CONCLUSIONS OF LAW 1. Due to the death of the Veteran, the Board has no jurisdiction to adjudicate the merits of this appeal at this time. 38 U.S.C. § 7104(a); 38 C.F.R. § 20.1302. 2. The criteria for service connection for cause of death are met. 38 U.S.C. §§ 1110, 1310, 1154, 5107; 38 C.F.R. § 3.102, 3.303, 3.307, 3.309, 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1942 to November 1945. He died in November 2012. The appellant is his surviving spouse. In April 2019 the Board issued a decision denying the claim of entitlement to accrued benefits and entitlement to service connection for cause of death. The appellant appealed that decision to the Court of Appeals of Veterans Claims (Court) and in an order dated February 2021, the Court set aside the Board's denial and remanded the issue for further development and readjudication pursuant to the terms of the joint motion remand (JMR). 1. Entitlement to accrued benefits At the time of the Veteran's death in November 2012, there was a claim pending for benefits based on the permanent incapacity for self-support of an adult son. Unfortunately, the Veteran died during the pendency of this appeal. The Board notes that a VA Form 21P-534EZ, Application for Dependency and Indemnity Compensation (DIC), Death Pension, and/or Accrued Benefits, was filed by the surviving spouse in February 2013, less than a year after the death of the Veteran. The February 2013 VA Form 21-534 is deemed to include a request for substitution. See 38 C.F.R. § 3.1010 (c) (2). Thus, the Veteran's surviving spouse currently has a substitution request pending before the AOJ; however, the AOJ has not yet made a formal determination as to whether the Veteran's surviving spouse is an eligible substitute in this appeal. See 38 C.F.R. § 3.1010 (e) (stating that the "the agency of original jurisdiction will decide in the first instance all requests to substitute, including any request to substitute in an appeal pending before the Board of Veterans' Appeals"). The Board does not have jurisdiction to grant such a request in the first instance. 38 C.F.R. § 3.1010. Accordingly, this appeal must be dismissed for lack of jurisdiction. 38 U.S.C. § 7104(a); 38 C.F.R. § 20.1302. 2. Entitlement to service connection for cause of death The appellant contends that the Veteran's causes of death, cardiopulmonary arrest with cerebrovascular accident are etiologically related to his service-connected PTSD. After a veteran's death, VA compensates certain beneficiaries, including surviving spouses, when the cause of death is a service-connected disability or the cause of death, while not service-connected, is related to service. 38 C.F.R. § 1310; 38 C.F.R. §§ 3.5 (a), 3.312. In order to establish service connection for the cause of death, the evidence must show that a disability incurred in or aggravated by service was either the principal cause of death or contributed substantially or materially to the veteran's death. 38 C.F.R. § 3.312. For a service-connected disability to constitute a contributory cause of death, it must be shown to have contributed substantially or materially to the veteran's death; combined to cause death; aided or lent assistance to the production of death; or resulted in debilitating effects and general impairment of health to an extent that would render the veteran materially less capable of resisting the effects of other disease or injury causing death, as opposed to merely sharing in the production of death. 38 C.F.R. § 3.312. The record contains conflicting opinions from the January 2016 VA examiner and Dr. M.C., a private clinician. In June 2016 the VA examiner opined that it is less likely than not that PTSD contributed to the death of the Veteran. The examiner explained that the Veteran's symptoms were mild in 2000 when he was initially service connected for PTSD; thus, indicating little, if any, psychosocial impairment. However, by his 2010 PTSD evaluation, his neurological condition (delirium) was so severe that it prevented him from directly describing his PTSD symptoms; as such, findings were based on information provided by his daughter. The examiner concluded that while a differentiation of symptoms was not completed at the time, most of his functional impairment was due to his delirium (or dementia). Thus, the difference in symptoms was due partly to dementia which was worsened by the stroke in 2009. While the article of record indicates a higher statistical risk for developing dementia for those with PTSD, PTSD is not a known cause of dementia and most individuals with it do not develop it. The primary cause of death is cerebrovascular accident, for which PTSD is not a known cause. In November 2021, the appellant provided an opinion from private clinician Dr. M.C., who opined that there is a nexus between the Veteran's PTSD and vascular pathology. The Board notes that Dr. M.C. reviewed the record, to include lay statements and provided a detailed medical history which includes a summary of symptoms and full citations for referenced medical literature. Based on this review, Dr. M.C. explained that the Veteran experienced severe mental illness from discharge of active service but went decades without treatment so that by the time he sought treatment in 2000 his disease was already intractable. Due to the lack of treatment, to include psychotherapy and pharmacological management, his symptoms progressed, which led to eventual strokes as his exaggerated startle response, nightmares, flashbacks, and avoidance behaviors elevated his heart rate and contributed to the development of cardiovascular problems, eventually resulting in his first stroke. In addition to PTSD, Dr. M.C. noted that the Veteran was diagnosed with refractory hypertension, which he believes to be causally associated with PTSD as medical literature has an overabundance of articles reviewing such a connection. Thus, the clinician concluded that it is as likely as not that there is a causal relationship between hypertension and PTSD with vascular pathology escalating in conjunction with his mental illness. To support this finding, Dr. M.C. cited two articles noting that persons with PTSD have an increased risk of hypertension, and possibly thromboembolic stroke and that multiple studies show that individuals with PTSD have increased heart rate and blood pressure. Thus, the Veteran's PTSD led to much higher risk of hypertension, which is the most predominant risk factor for cerebrovascular disease and stroke. Consequently, the Veteran's hypertension was directly caused by PTSD, which is also a direct causal disease process associated with cerebrovascular accidents and for the Veteran these two pathways combined to create a situation where hypertension led to more severe vascular pathophysiology, specifically cerebrovascular accident. Additionally, Dr. M.C. also opined that the Veteran had major neurocognitive disorder as he met all the diagnostic criteria for prior to death, which was clinically correlated to PTSD and led to cognitive decline. He noted that medical literature reveals a significant correlation between PTSD and the development of degenerative dementias. The provided citations note that in a predominately male veteran cohort those diagnosed with PTSD were at a nearly two-fold higher risk of developing dementia. Dr. M.C. reported that PTSD contributed to an increase of probability of dementia, which was a direct contributing factor to his profound deterioration. He reported that analysis of 21 different articles concluded that individuals with PTSD show signs of cognitive impairment more so than individuals exposed to trauma who do not have PTSD. This cognitive dysfunction led to a failure by the Veteran to consistently access medical and mental health care services. As cerebrovascular disease and accidents are directly related to hypertension, the Veteran inadvertently increased his risk for vascular disease of the brain due to his mental illness. The Board gives finds the opinion of Dr. M.C. competent, credible, and persuasive. This opinion was conducted by a health care professional, who reviewed the record and provided medical articles and studies to support his opinion with full citations. This opinion is well supported by an adequate rationale that contained clear conclusions with supporting data and a reasoned medical explanation. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board therefore concludes, when resolving reasonable doubt in the appellant's favor, that PTSD via hypertension lent aid and assistance to the production of the Veteran's death. See 38 U.S.C. § 5017 (b); 38 C.F.R. § 3.102. As a result, the criteria for service connection for cause of death have been met, and the claim is granted. See 38 C.F.R. § 3.312 (c)(1). G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.