Citation Nr: 21022638 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 17-42 131 DATE: April 16, 2021 REMANDED Entitlement to service connection for cause of death is remanded. REASONS FOR REMAND The Veteran served in the United States Army from July 1953 to June 1955, including during the Korean Conflict Era. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The appellant originally requested a hearing before the Board. However, in a November 2019 correspondence, the appellant’s representative waived her right to a hearing. The claim was remanded in February 2020 for further development. That development was completed, and the case has been returned to the Board for appellate review. Unfortunately, after review of the claims file, remand is necessary again for another medical opinion. Initially, the Board acknowledges a March 1954 service treatment record that noted the Veteran experienced chest pain while in service when the Veteran was under some sort of stress. It was interpreted as emotional stress and diagnosed as a psychogenic cardiovascular reaction. Notably, the Veteran’s separation examination listed his heart as normal. Additionally, at the time of his death or since that time, the Veteran was not and has not been service connected for a heart condition. The Veteran’s death certificate list the immediate causes of death as ventricular arrhythmia, cardiac arrhythmia, and morbid obesity. It is also noted that other significant conditions, such as hypercholesteremia, contributed to his death but was not a result of the underlying cause. At the time of his death, the Veteran was service-connected for bilateral pes planus with a 30 percent rating and bilateral hearing loss which was assigned a noncompensable rating. Following his death, the RO granted service connection for tinnitus. The appellant claims that the Veteran’s service-connected disabilities, namely his bilateral pes planus, caused or materially or substantially contributed his death. In a July 2017 statement, the appellant noted that as the Veteran got older his feet hurt more so he was unable to walk and do other exercises. As a result, his foot disability added to his morbid obesity, which is listed on his death certificate. Although obesity is not a disease or disability for VA compensation purposes and, thus, may not be service-connected on a direct or secondary basis, obesity may act as an "intermediate step" between a service-connected disability and a current condition that may be service-connected on a secondary basis under 38 C.F.R. § 3.310. In a June 2020 VA medical opinion, the examiner noted the Veteran’s service-connected disabilities and conditions listed on the certificate of death that caused and contributed to the Veteran’s demise. Following a review of the record, the VA examiner opined that the Veteran’s service-connected disabilities, specifically, his bilateral pes planus did not cause or materially contribute to his cause of death, including cardiac arrhythmia and obesity. He noted the most common causes of obesity to be a combination of excess food intake and lack of exercise. He indicated that bilateral pes planus does not preclude all forms of exercise. He noted, for instance, circumstances in which people who are paraplegics are able to exercise and maintain an appropriate body mass index with other forms of exercise. However, the Board finds this opinion to be inadequate as the VA examiner did not address whether in this case, the Veteran’s bilateral pes planus was a contributory cause of death. Specifically, he did not consider whether the disability combined to cause death; or that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c)(1). Therefore, remand is necessary for another medical opinion. The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction should refer the claims file to a suitably qualified VA examiner for a medical opinion to address the cause of the Veteran’s death. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and the appellant’s assertions. It should be noted that the appellant is competent to attest to factual matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner is requested to opine whether the Veteran's service-connected bilateral pes planus caused the Veteran to become obese; (2) if so, whether the obesity as a result of the bilateral pes planus was a substantial factor in causing or aggravating ventricular arrhythmia or cardiac arrhythmia; and (3) whether the ventricular arrhythmia or cardiac arrhythmia would not have occurred but for obesity caused by the service-connected bilateral pes planus. See VAOPGCPREC 1-2017 . Then, with consideration of the above, the examiner should provide an opinion as to whether it is at least as likely as not that the Veteran’s service-connected disabilities, specifically his bilateral pes planus, caused his death; contributed substantially or materially to his death; combined with another disorder to cause his death; or aided or lent assistance to his death. In rendering the above opinions, the examiner should consider the appellant’s contention that the Veteran’s service-connected disability contributed to his morbid obesity which led to his death. In a July 2017 statement, the appellant noted that as the Veteran got older his feet hurt more so he was unable to walk and do other exercises. As a result, his feet disability added to his morbid obesity. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. The AOJ should review the medical opinions to ensure that it is in compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M. Walker 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.