Citation Nr: 21075837 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 19-20 157 DATE: December 21, 2021 ORDER Entitlement to service connection for frostbite of the right foot is granted. Entitlement to service connection for frostbite of the left foot is granted. REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a traumatic brain injury (TBI) is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for carpal tunnel syndrome of the right upper extremity is remanded. Entitlement to service connection for carpal tunnel syndrome of the left upper extremity is remanded. Entitlement to service connection for a bilateral eye disability is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a left shoulder scar is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, the evidence of record favors a finding that the Veteran's residuals of frostbite of the bilateral feet are related to his service. CONCLUSIONS OF LAW 1. The Veteran's residuals of frostbite of the right foot were incurred during his military service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. § § 3.102, 3.159, 3.303, 3.304(f), 3.310 (2020). 2. The Veteran's residuals of frostbite of the left foot were incurred during his military service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. § § 3.102, 3.159, 3.303, 3.304(f), 3.310 (2020). REASONS FOR FINDING AND CONCLUSIONS The Veteran served on active duty from August 1951 to February 1962 This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2013 and May 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2021 the Veteran and his wife Veteran testified at a videoconference hearing in front of the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claim file. Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, 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." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. 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). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Factual Background and Analysis The Veteran testified at his October 2021 hearing that he had residuals of frostbite injuries of his left and right feet which were incurred during his service in Korea. The Veteran's wife of 68 years also testified that she recalled her husband having frostbite of his feet when he served in Korea. The Veteran underwent a VA cold residuals examination in July 2013. It was noted that the Veteran was diagnosed with frostbite in 1953 as the Veteran reported that his feet were in the snow. His current symptoms were pain in his feet. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for residuals of frostbite of the bilateral feet disabilities is warranted. Initially, the Board notes that as there is a current diagnosis of residuals of frostbite of the bilateral feet the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). While the Veteran's service treatment records are negative for complaints of cold residuals or frostbite, the Board notes that in this instance, the Veteran has consistently maintained via statements and at his October 2021 hearing that he had frostbite while in Korea in 1953. Additionally, the July 2013 VA examiner noted that the Veteran was diagnosed with frostbite in 1953. The Veteran is competent to report his activities during his service. The Board finds no basis in the record to question the Veteran's credibility regarding his statements. The Veteran's statements are competent and credible. See Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding a veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses). As a result, when reasonable doubt is resolved in the Veteran's favor, this evidence is sufficient to corroborate the Veteran's reports of his in-service injury. Therefore, the in-service injury element has been met and the Board finds that when resolving all reasonable doubt in favor of the Veteran, the Veteran has current residuals of frostbite of the bilateral feet disabilities that were caused by his in-service frostbite. Additionally, a remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran's claims, and a remand would only serve to unnecessarily delay final adjudication of the claims. In this regard, the Board notes that the positive medical opinions of the July 2013 VA examiner are not contradicted by any other medical evidence or opinion. In sum, for the reasons and bases discussed above, the Board has resolved reasonable doubt in favor of the Veteran, and service connection for residuals of frostbite of the bilateral feet disabilities is granted. See 38 U.S.C. § 5107(b). REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claims on appeal. Notably, in a May 2015 rating decision, the RO granted denied entitlement to service connection for PTSD. In June 2018. In May 2015, the Veteran filed an informal notice of disagreement (NOD) as to the May 2015 rating decision. However, it appears that no subsequent statement of the case was ever issued. Under Manlincon v. West, 12 Vet. App. 238, 240 (1999), the Board must instruct the RO that the issue of entitlement to service connection for PTSD remains pending in appellate status and require further action. See 38 U.S.C. § 7105; 38 C.F.R. § 19.26. In this regard, it is noteworthy that this claim is not before the Board at this time and will only be before the Board if the Veteran files a timely substantive appeal. The Board's actions regarding this issue are taken to fulfill the requirements of the Court in Manlincon. Regarding the claim for entitlement to service connection for hypertension, the Board notes that for hypertension, regulations provide that hypertension for VA purposes means that the diastolic blood pressure is predominantly 90 or more or systolic blood pressure is predominantly 160 or more. Hypertension must be confirmed by readings taken two or more times on three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). Notably, the Veteran's service treatment records contain instances of elevated blood pressure readings as evidenced by an April 1955 service treatment record which demonstrated a blood pressure reading of 130/80. While the Veteran previously underwent a VA examination for hypertension in July 2013 which provided a diagnosis of hypertension, no etiology opinion was provided. Thus, the Board finds that the evidence currently of record is insufficient to resolve the claim for entitlement to service connection for hypertension and that further development is warranted so an examiner can provide an opinion to determine whether the Veteran has a current hypertension disability, that is related to his service. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991); 38 C.F.R. § 3.159(c) (4). Regarding the Veteran's claims for service connection for a TBI, a right shoulder disability, a left shoulder disability, carpal tunnel syndrome of the right upper extremity, carpal tunnel syndrome of the left upper extremity, a bilateral eye disability, a back disability and a left shoulder scar, the Board notes that the Veteran testified that he was involved in a rollover motor vehicle accident during service which he claims resulted in his TBI, bilateral shoulder and back disability. The Veteran also contends that his carpal tunnel syndrome, scar of the left shoulder and bilateral eye disabilities resulted from the in-service rollover accident. The Veteran also testified that he did not receive treatment for these injuries during service as he "didn't have the time" but received treatment for these disabilities shortly after service. The Veteran's wife of 68 years also testified that she recalled her husband complaining about and receiving treatment for head, back and shoulder injuries. The Veteran previously underwent VA examinations in July 2013. The examiner noted that the Veteran had diagnoses of a TBI, carpal tunnel syndrome, a left shoulder scar, bilateral rotator cuff tears and end stage glaucoma. However, no etiology opinions were provided. Thus, the Board finds that the evidence currently of record is insufficient to resolve the claims for entitlement to service connection for a TBI, a right shoulder disability, a left shoulder disability, carpal tunnel syndrome of the right upper extremity, carpal tunnel syndrome of the left upper extremity, a bilateral eye disability, a back disability and a left shoulder scar and that further development is warranted so an examiner(s) can provide opinions to determine whether the Veteran has current TBI, a right shoulder disability, a left shoulder disability, carpal tunnel syndrome of the right upper extremity, carpal tunnel syndrome of the left upper extremity, a bilateral eye disability, a back disability and a left shoulder scar, that are related to his service. The matters are REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. The RO should issue a statement of the case addressing the matter entitlement to service connection for PTSD, including citation to all relevant law and regulation pertinent to this claim. Then, only if the appeal is timely perfected, this issue is to be returned to the Board for further appellate consideration, if otherwise in order. 3. After the above development has been accomplished, schedule the Veteran for an appropriate VA examination, to determine the nature and etiology of his claimed hypertension disability. The examiner should provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a current hypertension disability that is related to any incident of the Veteran's active duty service to include a claimed rollover motor vehicle accident. Adequate reasons and bases for any opinion must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 4. After the above development has been accomplished, schedule the Veteran for an appropriate VA examination, to determine the nature and etiology of his claimed TBI disability. The examiner should provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a current TBI disability that is related to any incident of the Veteran's active duty service to include a claimed rollover motor vehicle accident. Adequate reasons and bases for any opinion must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 5. After the above development has been accomplished, schedule the Veteran for a VA examination to determine the etiology of the claimed bilateral shoulder, carpal tunnel syndrome and left shoulder scar disabilities. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examiner should provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran has current bilateral shoulder, carpal tunnel syndrome and left shoulder scar disabilities that are related to any incident of the Veteran's active duty service to include a claimed rollover motor vehicle accident. Adequate reasons and bases for any opinion must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 6. After the above development has been accomplished, schedule the Veteran for an appropriate VA examination, to determine the nature and etiology of his claimed low back disability. The examiner should provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a current low back disability that is related to any incident of the Veteran's active duty service to include a claimed rollover motor vehicle accident. Adequate reasons and bases for any opinion must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 7. After the above development has been accomplished, schedule the Veteran for an appropriate VA examination, to determine the nature and etiology of his claimed bilateral eye disability. The examiner should provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a current bilateral eye disability that is related to any incident of the Veteran's active duty service to include a claimed rollover motor vehicle accident. Adequate reasons and bases for any opinion must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 8. Thereafter, readjudicate the issues on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James A. DeFrank, 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.