Citation Nr: 21016023 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 14-19 164 DATE: March 19, 2021 ORDER Entitlement to service connection for hypertension is denied. FINDINGS OF FACT 1. The Veteran's hypertension clearly and unmistakably pre-existed her third period of active service and clearly and unmistakably was not aggravated by her third period of active service. 2. The Veteran’s hypertension did not otherwise manifest during active service and is not otherwise causally or etiologically related to her active service. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1111, 1131,1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306 REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from March 1980 to June 1980, from February 1981 to November 1988, and from March 2003 to June 2003. This case comes before the Board of Veterans’ Appeals (Board) on appeal of a December 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in April 2017. Entitlement to service connection for hypertension The Veteran contends that her hypertension is due to her third period of active duty service, from March 2003 to June 2003. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A veteran is presumed to be in sound condition when she entered into military service, except for conditions noted on the entrance examination. 38 U.S.C. § 1111. If a preexisting disorder is noted upon entry into service, service connection may still be granted based on aggravation during service of that disorder. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b); see Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disorder during such service, unless there is a specific finding that the increase in disorder is due to the natural progress of the disease. 38 U.S.C. § 1153; 38C.F.R. §3.306(a). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disorder underwent an increase in severity during service. 38 C.F.R. § 3.306(b). Evidence that is clear and unmistakable is that which "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). When the veteran is presumed sound at entrance, the burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096. In Horn v. Shinseki, the United States Court of Appeals for Veterans Claims (CAVC or Court) explained that even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness. Rather, the burden is on VA to establish by clear and unmistakable evidence that the pre-existing condition did not worsen during service or that any increase in severity was due to the natural progress of the disease. Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. A review of the claims file reflects that the Veteran’s service treatment records (STRs) contain a notation that the Veteran had hypertension and was on medication for the condition in December 2002. The Veteran wrote that she was on medication for high blood pressure and the physician noted “HTN-on med.” During an April 2003 examination the Veteran’s blood pressure was 130/88. At a physical in May 2003, the Veteran’s blood pressure was 118/72. On question 16(f) of the May 2003 physical, the Veteran was asked if she had high or low blood pressure. The Veteran selected “no.” The Veteran only listed her current medications as those for GERD. During an April 2004 physical, the Veteran’s blood pressure was measured at 136/90, 131/63, and 124/82. On question 16(f) of the physical, the Veteran was asked if she had high or low blood pressure. The Veteran selected “yes” and wrote “sometimes” next to her selected answer. Post-service VA treatment records dated October 2007 show a diagnosis of hypertension. An August 2011 VA treatment record reflects that the Veteran was taking medication, Lisinopril, for her hypertension condition. The Veteran was afforded a VA hypertension examination in November 2012. A diagnosis of hypertension was provided. The Veteran reported being diagnosed in 2007 and being prescribed medication at that time. She noted that during service, her blood pressure was elevated on two occasions, but was not given a diagnosis of hypertension or placed on medication. She indicated that she remained on medication, which she tolerated without difficulty. It was noted that she took Lisinopril. Blood pressure readings of 131/76 on July 31, 2012, 147/86 on July 6, 2012, and 139/82 on April 27, 2012 were indicated. The VA examiner noted a review of the Veteran’s records which showed that she was not given a diagnosis of hypertension until 2007. A record dated in September 1987 was incorrectly tabbed to show a diagnosis of vasovagal reaction versus hyperventilation. The examiner reported that a December 2002 medical certificate shows that the Veteran was taking medication for high blood pressure and no specific medication was identified. At the Veteran’s April 2017 Board hearing, she reported feeling sick and experienced headaches while in service. Around 2003-2004, the Veteran reported to sick call where she was told her blood pressure was elevated. The Veteran stated while at sick call she was asked whether or not there has been a diagnosis of high blood pressure. The Veteran answered in the negative. The Veteran went on to state that she was diagnosed with high blood pressure at that time. The Board notes the Veteran’s lay testimony of record that she began experiencing symptoms while on active duty. While she is competent to report having experienced symptoms since service, she does not have the training or credentials to provide a competent opinion as to a diagnosis or etiology in this case. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In addition, the testimony from April 2017 April contradicts the medical records in the file where she wrote that she was on medication for high blood pressure in December 2002. This case was remanded in January 2018 because the Board found the November 2012 VA examiner did not provide an etiology opinion for a disability noted to be present. The Veteran was also afforded a VA opinion in May 2018. The VA examiner opined that it was less likely as not that the Veteran’s hypertension had its onset during or caused by or otherwise related to active duty because the Veteran’s service treatment records were silent for a diagnosis of hypertension or sustained elevated blood pressure readings during the first and second periods of active duty and because she reported being treated for hypertension in 2002, prior to entry into the third period of active duty in 2003. The medical knowledge to determine the natural progression of hypertension in an individual did not exist. The VA examiner also stated that during the third active period of active duty, the Veteran’s blood pressure stayed under control. Therefore, it is less likely as not that hypertension was aggravated by active duty. The Board remanded this case in February 2019. The Board found that the May 2018 medical opinion regarding the third period of active service was inadequate. The claim was remanded to obtain a VA medical opinion requesting that the VA examiner determine whether the Veteran’s hypertension clearly and unmistakably preexisted the Veteran’s third period of service. The October 2019 VA medical addendum report shows that the Veteran took Lisinopril for her condition and blood pressure readings of 111/71 on April 20, 2018, 135/81 on March 12, 2018, and 138/75 September 13, 2017 were indicated. The VA examiner stated that it was less likely as not that there was a causal link between hypertension and the third period of service, because hypertension was diagnosed clearly and unmistakably prior to third period of service with hypertension and being on medication. The examiner noted a diagnosis of hypertension in December 2002. The Veteran’s separation physical after the second period of active and medical records until 1999 were silent for hypertension. The VA examiner stated that the medical knowledge to determine the precise natural progression of hypertension in an individual did not exist. As such, there was “no evidence to support hypertension being clearly and unmistakably aggravated by any event during and by, the third period of service.” Regardless, there was no evidence of uncontrolled hypertension during the third period of active service. In August 2020 the case was remanded again because the February 2019 VA examiner utilized an incorrect standard in determining the applicability of the presumption of soundness. The question of the second prong of that standard is whether hypertension was NOT clearly and unmistakably aggravated by the third period of service. The opinion regarding “no evidence to support hypertension being clearly and unmistakably aggravated by any event during and by, the third period of service” was not responsive to the Board’s prior remand. The Veteran was afforded another VA examination in October 2020. The examiner stated it was less likely than not that the Veteran’s hypertension is etiologically related to the third period of service. The examiner opined that the Veteran’s hypertension existed prior to her third period of service and therefore, the third period could not have contributed to the condition. However, the VA examiner utilized an incorrect standard in determining the applicability of the presumption of soundness for the second time. The question for the examiner in the August 2020 remand was to ascertain whether hypertension clearly and unmistakably preexisted the third period of service. The VA examiner opined “Yes, Pre-existed service” and “Less likely that hypertension is due to or aggravated by the third period of service from March-June 2003.” The opinion submitted by the VA examiner was not responsive to the Board’s prior remand to use the specific language (clearly and unmistakably preexisted the third period of service) and was remanded by the Board in January 2021. As a result of the January 2021 Board remand, the Veteran was afforded a VA record review and opinion. The examiner found that hypertension clearly and unmistakably preexisted the third period of service. The examiner explained that hypertension requiring medication was noted on an examination prior to the third period of service. The examiner noted that the first evidence of a hypertension diagnosis was found in medical records from December 2002. These records indicated daily medication for hypertension was required and confirmed the diagnosis prior to third period of service. Additionally, the examiner found that the Veteran’s hypertension clearly and unmistakably was not aggravated by the third period of service. The examiner found no evidence of aggravation or uncontrolled blood pressure readings in the Veteran’s medical records between March 2003 and June 2003. Examinations in 2003 and 2004 indicate blood pressure controlled with medication. The examiner did not find any evidence of a specific event, illness, or exposure during service that could have caused or aggravated the hypertension. The Board finds this January 2021 report to be probative and deserving of weight, as the examiner reviewed the medical history from a review of the claims file. Additionally, the examiner made a clearly articulated conclusion and supplied a rationale. Taken together, the VA opinions, examinations, and medical records discussed above establish that there is clear and unmistakable evidence that demonstrates that the Veteran’s hypertension existed before acceptance and enrollment in the third period of service. Also, the Board finds clear and unmistakable evidence that the Veteran's hypertension did not increase in service or that any increase was not due to the natural progress of the condition. The Veteran clearly noted her hypertension prior to her third period of service in December 2002 and her blood pressure remained stable through the third period of service. Additionally, the Veteran’s hypertension did not manifest during active service and is not otherwise causally or etiologically related to her active service. In reaching the above determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107; Gilbert, 1 Vet. App. at 55-56. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Hetman 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.