Citation Nr: 21015472 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 18-13 860 DATE: March 17, 2021 ORDER Service connection for the cause of the Veteran’s death is granted. FINDING OF FACT The medical evidence is in relative equipoise regarding whether the Veteran’s service-connected PTSD disability was a contributory cause of his death. CONCLUSION OF LAW The criteria to establish service connection for the cause of the Veteran’s death have been satisfied. 38 U.S.C. §§ 1110, 5107 (b) (West 2014); 38 C.F.R. §§ 3.102, 3.312 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from July 1968 to July 1970. The Veteran died in 2008, and the appellant is the Veteran’s widow. The case was remanded in May 2019 for evidentiary development and for medical opinions. All actions ordered by the remand have been accomplished. Dependency and Indemnity Compensation (DIC) In a claim of service connection for a veteran’s cause of death, i.e., Dependency and Indemnity Compensation (DIC), evidence must be presented that links the fatal disease to a period of military service or to an already service-connected disability. 38 U.S.C. §§ 1110, 1310; 38 C.F.R. §§ 3.303, 3.312. Evidence must be presented showing that a service-connected disability is either the principal or contributory cause of death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. DIC is also awarded if the veteran’s death can be service connected. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. That is, service connection for the cause of a veteran’s death may be granted if the evidence shows that a fatal disease or injury was actually incurred or aggravated in service, though service connection had not been granted for the disease or injury prior to a veteran’s death, was either the principal or a contributory cause of death. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish service connection for the cause of a veteran’s death, due to a cause not already service connected, the evidence must show that a disability that either was incurred in or aggravated by service, or which was proximately due to or the result of a service-connected condition, was either a principal or contributory cause of death. 38 U.S.C. §§ 1101, 1112, 1113, 1310; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (a), 3.312 (a); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992), citing Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). For a service-connected disability to be the principal cause of death, it must singularly or jointly with some other condition be the immediate or underlying cause of death, or be etiologically related thereto. 38 C.F.R. § 3.312 (b). For a service-connected disability to be a contributory cause of death, it must be shown that it contributed substantially or materially, that it combined to cause death, or aided or lent assistance to the production of death. 38 C.F.R. § 3.312 (c). As a general matter, service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). “To establish a right to compensation for a present disability, a [claimant] 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)). Disorders diagnosed after discharge will still be service-connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for the cause of the Veteran’s death The Appellant contends the Veteran’s service-connected posttraumatic stress disorder (PTSD) was a contributory cause of death because it either contributed substantially or materially to the Veteran’s death; combined with his hypertension to cause his death; or aided or lent assistance to the production of his death. The Veteran was service-connected for PTSD at 50 percent disabling since April 28, 1994, until his death. At the October 1997 VA medical examination for PTSD, the Veteran reported a family history of diabetes and hypertension. He also reported a relapse of cocaine use in May 1997 due to increased PTSD symptoms. The examiner noted the Veteran endorsed being short tempered and being unable to relate to people. The examiner also noted the Veteran was afraid of loss of control and that he had panic attacks with depression and isolation. The Veteran also had reduced initiative, flexibility, efficiency and reliability. In January 1998 the Veteran was assessed with probable hypertension. In a followup consultation the examiner noted the Veteran was non-compliant with his prescription hypertension medications. The Veteran reported he did not take his hypertension medication because the line was too long at the pharmacy. October 2001 private treatment records indicate the Veteran had “uncontrolled” hypertension. Also in October 2001 an echocardiogram revealed hypertensive cardiovascular disease. In January 2002 the Veteran’s treating physician encouraged the Veteran to comply with his blood pressure medication regimen. In December 2008 the Veteran was seen in the emergency room. A subsequent CT scan indicated the Veteran demonstrated a “fairly large” intracranial hemorrhage. The examiner noted the Veteran was markedly hypertensive when he entered the emergency room and that the Veteran had a history of uncontrolled hypertension. The physician reported he admitted the Veteran to the intensive care unit with a diagnosis of altered mental status and acute intracranial hemorrhage. Hospital discharge records indicate the Veteran’s cause of death was noted as respiratory failure secondary to a massive basal ganglion bleed, hypertensive in origin. The Veteran’s 2008 death certificate indicates the cause of death was cardiopulmonary arrest; intracerebral hemorrhage; and hypertension. In a May 2018 statement, the Appellant stated that the Veteran told her that drugs were his “escape” from his thoughts and feelings. The Appellant noted the Veteran was unable to stop abusing drugs the entire time they were married, and that the Veteran “struggled” with blood pressure and drug abuse until he died. The Appellant further stated that the Veteran had a history of forgetting to take his blood pressure medication, and that the Veteran’s VA physician stopped prescribing hypertension medication patches to address this forgetfulness. These lay statements are competent regarding their observations of the Veteran’s behavior and conversations, and to establish the presence of observable symptomatology, including frequency. See Caluza v. Brown, 7 Vet. App. 498 (1995); see also Barr v. Nicholson, 21 Vet. App. 303, 307-8 (2007). While also presumed credible, these observations are not competent to provide a nexus between the Veteran’s service-connected PTSD disability and his causes of death. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). In a May 2018 private medical opinion, Dr. H.S. reviewed the Veteran’s claims file and noted that the physiology of PTSD, depression and anxiety activates hormonal responses that control blood pressure and results in overstimulation and increased heart rate. The examiner noted that medical research indicated that the rate of hypertension increases in persons with high or intermediate depressive symptoms versus low depressive symptoms. The examiner also noted that the National Stroke Association states that high blood pressure is one of two of the most common causes of an intercerebral hemorrhage stroke. Based on his review of the Veteran’s claims file, the medical literature, and the Appellant’s statements, the examiner opined the Veteran’s service-connected PTSD more likely than not aided in the development and permanent aggravation of his hypertension. He also opined that the Veteran’s PTSD, combined with his hypertension, more than likely contributed both substantially and materially to the intracerebral hemorrhage that caused his death. In an October 2019 VA medical opinion, a VA examiner reviewed the Veteran’s claims file, to include Dr. H.S.’s opinion. She concluded that it was less likely than not that the Veteran’s causes of death, to include hypertension, intercerebral hemorrhage, and/or cardiopulmonary arrest, were proximately due to or aggravated by the Veteran’s service-connected PTSD disability, to include his psychiatric medication. She noted that the medical literature cited by Dr. H.S. did not show evidence of a direct etiological link between PTSD and hypertension. She further opined there was “no evidence” to support the contention that the Veteran’s PTSD permanently aggravated the Veteran’s hypertension and subsequent stroke. She noted that the Veteran’s hypertension was poorly controlled due to non-compliance with medication protocols. In a May 2020 addendum opinion, the same VA examiner reviewed additional medical treatise evidence. She reaffirmed her opinion that there was insufficient evidence to support the conclusion that the Veteran’s PTSD caused the Veteran’s hypertension, or other two causes of death. She noted that hypertension was poorly understood, had numerous genetic and environmental factors, and that the Veteran demonstrated several risk factors for the development of hypertension, to include age, race, and family history. In an August 2020 private medical opinion, Dr. S.E. reviewed the Veteran’s claims file, including the additional VA opinions. He noted that the Veteran served in Vietnam and was therefore presumed to have been exposed to Agent Orange. The physician noted that that since the National Academy of Science (NAS) Institute of Medical (IOM) upgraded the associated of Agent Orange and hypertension to “sufficient,” he opined that the Veteran’s hypertension was caused by his service. He also addressed the VA examiner’s opinion that there was no direct etiological or causational link between the Veteran’s PTSD and his development of hypertension by noting that the Veteran had several risk factors that contributed to the development and continued difficulties with his blood pressure, but that the cellular changes caused by his chronic stress and the long-term damage from his hypertension and PTSD would have contributed to his risk of an intracerebral hemorrhage. The physician opined that the Veteran’s hypertension and PTSD contributed substantially and materially to the Veteran’s cause of death. The claim for service connection for the Veteran’s cause of death is granted. The medical evidence is in relative equipoise regarding whether the Veteran’s service-connected PTSD disability was a contributory cause of his death. Affording the Appellant the benefit of the doubt, since the Veteran’s service-connected PTSD disability was a contributory cause of death, the claim for service connection is granted. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Anwar, Attorney-Advisor 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.