Citation Nr: 21022368 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 13-36 417 DATE: April 15, 2021 ORDER Service connection for the cause of the Veteran's death is denied. FINDINGS OF FACT 1. The Veteran died in March 2001, due to arteriosclerotic coronary artery disease, hypertensive heart disease and end stage renal disease. 2. Neither arteriosclerotic coronary artery disease, hypertensive heart disease nor end stage renal disease was present during active duty or for years thereafter, and none of the disabilities was etiologically related to the Veteran's active military service. 3. At the time of his death, the Veteran was service connected for bilateral Dupuytren’s contracture (Dupuytren’s syndrome) and synovitis, right knee with degenerative joint disease and possible medial meniscus tear (right knee disability). 4. None of the Veteran's service-connected disabilities played a material causal role in his death. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran's death are not met. 38 U.S.C. § 1310 (2012); 38 C.F.R. § 3.312 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from July 1946 to October 1946, June 1955 to June 1956, and from July 1979 to September 1980. He died in March 2001. The appellant is his surviving spouse. The appellant testified before the undersigned at a June 2017 Video Conference hearing. The hearing transcript is of record. In October 2017 and August 2019, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. Legal Criteria 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; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic disabilities, including cardiovascular-renal disease and hypertension, to a degree of at least 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). DIC benefits are payable to the surviving spouse of a veteran if the veteran died from a service-connected disability. 38 U.S.C. § 1310 (2012); 38 C.F.R. § 3.5 (2019). The death of a veteran will be considered as having been due to a service-connected disability when the evidence establishes that such disability was either the principal or a contributory cause of death. The issue involved will be determined by exercise of sound judgment, without recourse to speculation, after a careful analysis has been made of all the facts and circumstances surrounding the death of the veteran, including, particularly, autopsy reports. 38 C.F.R. § 3.312(a) (2019). The service-connected disability will be considered as the principal (primary) cause of death when such disability, singly or jointly with some other condition, was the immediate or underlying cause of death or was etiologically related thereto. 38 C.F.R. § 3.312(b) (2019). A contributory cause of death is inherently one not related to the principal cause. In determining whether the service-connected disability contributed to death, it must be shown that it contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. § 3.312(c)(1) (2019); see also Gabrielson v. Brown, 7 Vet. App. 36, 39 (1994). Service connection for the cause of the Veteran's death The certificate of death indicates that the Veteran died in March 2001. The immediate cause of death was certified to be arteriosclerotic coronary artery disease, with hypertensive heart disease and end stage renal disease listed as other significant conditions contributing to death but not resulting in the underlying cause. The appellant does not contend, and the record does not show, that the Veteran's arteriosclerotic coronary artery disease, hypertensive heart disease or end stage renal disease was incurred in service. In this regard, service treatment records do not contain evidence of arteriosclerotic coronary artery disease, hypertensive heart disease or end stage renal disease during active duty or at the time of the Veteran's discharge from service. Furthermore, neither arteriosclerotic coronary artery disease, hypertensive heart disease or end stage renal disease may be presumed incurred during active military service, as there is no evidence that the Veteran manifested arteriosclerotic coronary artery disease, hypertensive heart disease or end stage renal disease to a degree of at least 10 percent disabling within one year after his active military service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a). Also, the record does not contain a medical opinion linking the Veteran's fatal arteriosclerotic coronary artery disease, hypertensive heart disease or end stage renal disease to his military service. The appellant contends that service connection is warranted for the cause of the Veteran's death because the Veteran’s service-connected Dupuytren’s syndrome and right knee disability caused or aggravated his arteriosclerotic coronary artery disease, which is listed as the immediate cause of death, as well as his hypertensive heart disease and end stage renal disease, which were listed as other significant conditions contributing to death, but not resulting in the underlying cause. Specifically, the Appellant asserts that due to the Veteran’s service-connected disabilities, he could not participate in cardiac strengthening programs, thus causing him to be completely inactive at the time of his death. Initially, the Board notes that although the appellant suggested during the June 2017 Board hearing that the Veteran also had a service-connected back disability that contributed to his inability to do cardiac strengthening exercises, as noted above, the Veteran was only service-connected for Dupuytren’s syndrome and a right knee disability. See June 2018 Deferred Rating Decision. Significantly, none of his service-connected disabilities are listed as a main or contributory cause of death on his death certificate. Furthermore, the Board finds that there is no evidence of record which shows a relationship between the Veteran's service-connected disabilities and the cause of his death. There is no medical evidence of record showing that any of the Veteran's service-connected disabilities had actually increased in severity prior to his death, and no evidence of record to show that the Veteran was totally and permanently disabled due to his service-connected disabilities alone. Moreover, the evidence of record does not show that any of the Veteran's service-connected disabilities contributed to the arteriosclerotic coronary artery disease that caused his death or the hypertensive heart disease and end stage renal disease, which contributed to his death. Pursuant to the Board’s October 2017 remand, a VA medical opinion was obtained as to whether the Veteran’s service-connected Dupuytren’s syndrome and right knee disability contributed to the Veteran’s cause of death. While the September 2018 VA medical opinion provider indicated that it is less likely than not that the Veteran’s Dupuytren’s syndrome and right knee disability contributed to the Veteran’s cause of death, stating that post-service treatment records are silent for any increased rating claims and that there is no supporting evidence that the Veteran’s service-connected disabilities would have predisposed the Veteran to a heart condition, the Board finds that the opinion is inadequate, as it is conclusory in nature and does not address in detail whether the Veteran’s service-connected disabilities caused or aggravated the Veteran’s arteriosclerotic coronary artery disease, hypertensive heart disease, and end stage renal disease. As such, and in accordance with the Board's August 2019 remand, and October 2019 VA examiner reviewed the Veteran's records and rendered an opinion on the relationship between the Veteran's service-connected disabilities and the cause of his death. The examiner concluded that it is less likely than not that either of the Veteran’s service-connected disabilities, including Dupuytren’s syndrome and his right knee disability, directly caused or contributed to the demise of the Veteran. The examiner explained that Dupuytren's contracture is a fibrotic condition of the palms of the hands with strong genetic and occupational predispositions that resulted in the Veteran’s inability to continue to perform surgical procedures. Both degenerative arthritis of the knee and Dupuytren's contracture have no clinical or pathophysiologic relationship to the disabilities (arteriosclerotic coronary artery disease, hypertensive heart disease, end stage renal disease) that caused the Veteran’s death. He also noted that there is no biologically plausible mechanism to suggest a possible nexus between Dupuytren's contracture and the disabilities that caused the Veteran’s death. The examiner also opined that it is less likely than not that either of the Veteran’s service-connected disability contributed directly or indirectly or via a secondary mechanism to the cause of death in the Veteran. The examiner explained that despite the service-connected right knee disability, clinical information in the claims file indicates that the Veteran was physically active throughout his life and not totally inactive, as suggested by the appellant. Also, there was no clinical documentation of severe progression in his service-connected right knee disability. The examiner concluded that more likely than not, the progressive burden of clinical illness related to atherosclerotic coronary and hypertensive heart disease leading to end-stage renal disease resulted in loss of aerobic capacity and later total inactivity, and not the service connected right knee disability. Thus, it is less likely than not that either service-connected disability contributed directly or indirectly or via a secondary mechanism to the cause of death in the Veteran. (Continued on the next page)   There is no other competent evidence of record indicating that the Veteran's service-connected disabilities, including Dupuytren’s syndrome and his right knee disability, caused or contributed to his death, or caused an increase in the severity of any of the medical problems which did cause his death. Accordingly, the Board must conclude that the preponderance of the evidence is against the appellant's claim and the claim must be denied. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board F. Yankey, 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.