Citation Nr: 21026747 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 14-25 718 DATE: May 3, 2021 ORDER Service connection for the cause of the Veteran's death is denied. FINDINGS OF FACT 1. The Veteran died from injuries sustained in a motor vehicle accident caused by a driver who wrongly entered his lane. 2. During the Veteran's lifetime, service connection was established for a cognitive disorder and dementia, status post resection left temporal anaplastic oligodendroglioma due to cancer of the brain, as well as for degenerative disc disease, laceration of the left foot, and laceration of the left index finger. 3. The Veteran's service-connected disabilities are not shown to have caused or contributed substantially or materially to the cause of his death, including by compromising cognitive functioning in a way that played a role in the accident. 4. The Veteran's service-connected residuals of brain cancer and resection are not shown to have been a factor in his death by causing him to be less capable of resisting the effects of the injuries he sustained in the car accident, or to have had a material influence in accelerating his death from those injuries. CONCLUSION OF LAW The criteria for service connection for the cause of the Veteran's death have not been met. 38 U.S.C. §§ 1110, 1131, 1310, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran completed an honorable career in the United States Air Force, serving on active duty from June 1975 to December 1995. The appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matter for further development in February 2018 and January 2019. It denied service connection for the cause of the Veteran's death in a June 2019 rating decision. In a November 2020 Order United States Court of Appeals for Veterans Claims (Court) granted a joint motion for remand (JMR) and vacated the Board's June 2019 decision, remanding the matter for action consistent with the terms of the JMR. In this regard, the parties agreed that the Board's June 2019 decision failed to address the provisions of 38 C.F.R. § 3.312(c)(3), regarding service-connected diseases or injuries involving active processes affecting vital organs. The appellant testified at a hearing before the undersigned Veterans Law Judge in January 2017. A transcript of the hearing is of record. Cause of the Veteran's Death The appellant claims service connection for the cause of the Veteran's death on the basis that his service-connected cognitive impairment with dementia was a factor in the motor vehicle accident in which he died. More specifically, she states that the Veteran was not able to react in time to avoid the collision due to impairment in his ability to process and store information. See January 2017 Hearing Transcript. She also notes that the Veteran's physician had discussed taking him off anti-seizure medication that had been prescribed for his service-connected disability because it contributed to his slower thinking. She has submitted two medical opinions in support of her claim, which will be discussed below. For the following reasons, the Board finds that service connection for the cause of death is not established. I. Law A surviving spouse of a qualifying veteran who died as a result of a service-connected disability is entitled to receive dependency and indemnity (DIC) compensation. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. To establish service connection for the cause of death and thus entitlement to DIC benefits, the evidence must show that a service-connected disability was either the principal or contributory cause of death. 38 U.S.C. § 1310; 38 C.F.R. § 3.312(a). A service-connected disability will be considered the principal (primary) cause of death when the disability singly or jointly with some other condition was the immediate or underlying cause of death, or etiologically related to such cause. 38 C.F.R. § 3.312(b). A contributory cause of death is inherently one not related to the principal cause, but which contributed substantially or materially to the cause of death. 38 C.F.R. § 3.312(c)(1). Service-connected diseases or injuries involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. 38 C.F.R. § 3.312(c)(3). Where the service-connected condition affects vital organs as distinguished from muscular or skeletal functions and is evaluated as 100 percent disabling, debilitation may be assumed. Id. Service connection for the cause of a veteran's death may be established by showing that a disability for which service connection has already been awarded was the principal or a contributory cause of death. Hupp v. Nicholson, 21 Vet. App. 342, 352 (2007). Otherwise, the claimant must first establish service connection for a disability shown to have caused or contributed to the veteran's death. Id. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990) (when the evidence supports the claim or is in relative equipoise, the claim will be granted). II. Analysis The preponderance of the evidence shows that a service-connected disability did not cause or contribute to the Veteran's death. The Certificate of Death reflects that he died in December 2012 of "multiple traumatic injuries" sustained in a head-on collision with another vehicle. The form states that he was operating a motor vehicle which was struck by another vehicle heading the opposite direction that came into his lane of traffic. The "[a]pproximate interval onset to death" was "seconds." In other words, he died within seconds of the impact. A police report provides a similar description, noting that the car that collided with the Veteran's vehicle was on the wrong side of the roadway, and that the Veteran's car attempted to evade it. During the Veteran's lifetime, service connection was established for a cognitive disorder and dementia from resection of a brain tumor (i.e., "status post resection left temporal anaplastic oligodendroglioma"). Service connection was also in effect for degenerative disc disease, laceration of the left foot, and laceration of the left index finger. The record shows that the Veteran underwent a left frontotemporal craniotomy and resection of a temporal lobe mass in November 2006. He then underwent radiation treatment. Military treatment facility (MTF) records from Brooke Army Medical Center (BAMC) include a February 2007 neuropsychological report that cleared the Veteran for driving. The report is dated about three months after his November 2006 resection surgery, and states that although he had very poor verbal memory, which was a hallmark of left temporal lobe resection, he performed well in the areas most related to driving. In this regard, he demonstrated average to well above average visuospatial ability and attention to visual detail. His scores on measures of motor speed and speed of information processing were slightly above average. He also performed in the average to above average range on most measures of attention, concentration, and visual tracking. He had a slow response time on one measure of visual tracking, but his accuracy was better than that of the normative group, and it was noted that he may have been more cautious in his response style to maximize accuracy. His speeded performances on several other measures fell in the above average range. The evaluation concludes that overall, in terms of cognitive functioning, the Veteran was a "good candidate" to return to driving. A February 2007 MTF record notes that the Veteran had passed the state's driving test, and an April 2007 MTF record reflects that he was driving without problems. A January 2008 VA treatment record reflects that another neuropsychological assessment was conducted in December 2007. The report notes that the Veteran's performance was consistent with the February 2007 assessment. He demonstrated a very poor ability to process verbal information, and had scores in the average to above average range on a variety of tests of executive functioning requiring both visual and verbal reasoning. This record also notes that the Veteran drove himself to the appointment, but reported that he took the wrong road and was later than he wanted to be. He stated that he continued to have problems remembering information. As an example, he said he usually writes down directions so that he "won't get lost like he did today." An April 2010 letter from the Veteran's treating physician at BAMC notes the Veteran's history being diagnosed with an anaplastic oligoastrocytoma-oligodendroglial predominant-Grade III (i.e. a brain tumor) in 2006 after presenting with a one-year history of progressive memory loss. Resection was performed in November 2006. The Veteran then received chemoradiation. The letter goes on to state, in part, that a March 2010 magnetic resonance imaging study (MRI) of the Veteran's brain revealed a stable examination without evidence of disease recurrence. The letter adds that while the Veteran's post-treatment disease course had remained stable, he was "not without treatment-related and disease-related side effects." He continued to take Keppra daily for seizure prophylaxis, and a recent neuropsychological evaluation determined he was categorized as "DSM IV-Cognitive disorder [secondary] to Neoplasm (294.9) and Adjustment Disorder with Mixed Anxiety and Depression (309.28). These effects and disability had "greatly stabilized," but were very likely permanent in nature. A February 2011 private neurological treatment record states that the Veteran was "doing very well" and had "no recent changes from his neurologic baseline." He continued to have some word finding difficulties and short-term memory problems, but these problems were "chronic issues and [were] unchanged." The Veteran's death resulted from a car accident that occurred in December 2012. The police report shows that the accident occurred on a highway, and that his car was driving westbound. The other car was driving eastbound on the wrong side of the highway, and at 80 miles per hour, which was 15 mph above the speed limit of 65 mph. The Veteran's car "attempted to take evasive action" to avoid the oncoming car, and both cars collided on the eastbound lane of the roadway. The report indicates that the time of the accident and time of the Veteran's death were the same, meaning he died on impact. The other driver was airlifted to a hospital, where he died about nine hours later. The police report reflects that the driver was suspected to have been intoxicated. A blood specimen was obtained from him for that purpose, the results of which are not of record A February 2013 medical opinion from a private neurologist, B. Bower, M.D., states that the Veteran had a history of a brain tumor that was resected over six years earlier, and that it "is possible that his reaction time in instances that require[d] prompt reaction could be slowed[.]" In the October 2018 VA medical opinion, a VA neuropsychologist concluded that it was less likely than not that the Veteran's cognitive impairment and dementia or medication he was taking caused or contributed to the cause of death in terms of compromising his ability to avoid the December 2012 fatal car accident. The examiner explained that there was no indication in the medical records that the Veteran's cognitive deficits affected his speed of thinking or reaction time. The examiner noted that the February 2007 neuropsychological evaluation was completed three months after the Veteran's resection surgery, and while he was taking Keppra, and that his scores were generally in the average to above-average range on most measures of attention, concentration, and visual tracking. The examiner noted that the results of the December 2007 neuropsychological testing were essentially the same. The neuropsychologist observed that these results would be expected with a left temporal lobe resection. In this regard, as stated by the examiner, the Veteran likely exhibited deficits in memory for information and was easily overwhelmed with too much auditory input due to poor verbal memory, which was a function of the left temporal lobe; however, other brain functions required for operation of a motor vehicle were essentially well-preserved. A December 2018 medical opinion from a private physician's assistant, S. Clark, PA-C, states that there was greater than a 50 percent probability that the Veteran's medical conditions contributed significantly to the fatal car accident due to his having a poor reaction time caused by his brain tumor resection with resultant short-term memory loss and mild cognitive disorder, as well as the effects of anti-seizure medications prescribed as treatment for residuals of the resection. The evidence of record does not show that the car accident in which the Veteran died was caused in any way by a slowed reaction time or any aberrancy in the way he was driving or responded to the oncoming vehicle. In this regard, the police report reflects that the speed limit on the highway where the accident occurred was 65 miles per hour, and that the car that wrongly entered the Veteran's lane and struck his car was traveling 80 miles per hour. It also reflects that no "contributing factors" with respect to the Veteran's vehicle were noted. Conversely, two contributing factors were recorded with respect to the other vehicle, as denoted by the numbers 70 and 61 in section 36 of the form. Although the Board is unable to decipher the meaning of those numbers as there is no key to the form, their presence on the report pertaining to the vehicle that struck the Veteran's car, and their absence on the report pertaining to the Veteran's car, indicates that only the other vehicle was found to have been at fault in the accident. Indeed, the driver of the vehicle that wrongly entered the Veteran's lane, and who also died as a result of the accident, was suspected to be intoxicated, and was driving 15 miles over the speed limit. Even if neither vehicle was at fault in the accident, there is still no indication from the police report that the Veteran had a slowed reaction time or other cognitive impairment that contributed to the accident, such as by responding to the car in an aberrant manner. The Board here notes that the JMR states that the Board "should be cognizant that for purposes of a determination as to whether the Veteran's service-connected disabilities were the principal or a contributory cause of death under 38 C.F.R. § 3.312(c), the standard under this regulation should not be conflated with the concept of contributory fault as contemplated under tort law." The Board clarifies that it uses the words "contributed" and "fault" not with respect to the criteria under § 3.312 in terms of whether a service-connected disability contributed to the biological mechanism of death, but for the purpose of explaining that not only are the records pertaining to the accident negative for any aberrancy in the Veteran's driving, but they show findings supporting the logical conclusion that the accident occurred solely as a result of the other driver's actions. In other words, the Board uses "contributed" in the same sense as it is used in the December 2018 medical opinion by S. Clark, PA-C, which states that the Veteran's "medical conditions contributed significantly " to the fatal car accident by causing a reduced reaction time. Thus, the word "contributed" is not used with respect to the biological mechanism of death, but to the external circumstancesi.e. the car accidentthat set that mechanism in motion. In that sense, the Board finds that the evidence does not establish that there was a delayed reaction on the Veteran's part that contributed to the collision from which his death resulted. Similarly, the Board uses the word "fault" above to explain its finding that the record does not show that the Veteran's driving, including a possibly slowed reaction time, played a role or was a factor in the accident. To the extent the appellant and the medical opinions state that the accident might nevertheless have been less severe or avoided had the Veteran's cognitive functioning not been impaired, that is pure speculation. Regardless of whether his cognitive functioning was impaired with respect to processing and responding to visual cuesalthough that is not established, as explained belowthere is still no evidence showing or even suggesting that his driving or response to the oncoming vehicle was in fact aberrant in any way, while there is probative evidence showing that the oncoming vehicle was driving very fast80 miles per hour where the speed limit was 65 miles per hourand wrongly entered the Veteran's lane when the collision occurred. The evidence does not show that an ordinary driver without any cognitive impairment would have had sufficient time to react to the oncoming vehicle so as to avoid the collision under these circumstances. In a November 2020 brief, the appellant stated that, according to the police report, the speedometer on the Veteran's vehicle was found to have been "locked on" 55 miles per hour at the time of the crash. The appellant adds that it was broad daylight and there was unlimited visibility on a road that the Veteran knew well. The appellant states that this shows that, despite the Veteran having a clear view of the car "barreling toward him in the wrong lane," he did not even apply his brakes "such that his cruise control would have turned off." The Board finds that these circumstances do not support a finding of a slowed response time. In the first place, the phrase "locked on" in the police report was not necessarily used in the sense that the car was on cruise control at 55 mph. Although the Board is not certain, it likely means that due to the crash, the speedometer had essentially "locked" or froze at the speed the Veteran was driving at the time due to the force of the impact, which may in fact have been a reduced speed from application of the brake pedal compared to the speed at which he had been driving before he saw the oncoming vehicle. As noted above, he was driving on a highway where the speed limit was 65 mph, which indicates that the speed of 55 mph may have been a reduction in speed due to application of brakes. That said, regardless of whether his car had been on cruise control or whether there is evidence he did or did not apply the brakes, it still would not in itself support a finding of a slow response time. The fact that the oncoming car entered the wrong lane at 80 miles per hour, that the Veteran swerved to evade the car, and that, as indicated in a diagram, the other car also swerved around the same time, resulting in the head-on collision, indicates that the circumstances leading up to the crash happened very quickly and unexpectedly, even though in broad daylight with good visibility. It would thus be in keeping with these circumstances that the Veteran lacked sufficient time to apply the brakes or apply them long enough to reduce his speed below 55 mph, not because he was slow in his response, but because the sequence of actions leading to the accident unfolded so rapidly. There is simply no evidence from the face of the police report or any other records that the Veteran's car responded in a delayed or aberrant manner. Because the private medical opinions are merely speculative in their assertion that the Veteran may have had a slow reaction time that contributed to the accident, with no supporting evidence that such was the case, they lack probative weight. Indeed, as just discussed, the available evidence supports a finding that the accident was solely the result of a driverwho was suspected to be intoxicated wrongly entering the Veteran's lane at 80 miles per hour, and was not due to any aberration in the Veteran's response, including a lack of response or slowed response as compared to an average person with no cognitive impairment, to that driver's action. As the evidence does not show that the Veteran had a slowed reaction to the oncoming vehicle which played a role in the fatal collision, the issue of whether in general his cognitive impairment was manifested by a deficiency in visuospatial processing such as a slowed reaction time, or otherwise affected his ability to drive safely, is moot: that is, even if such deficiency were established, it would not alter the Board's finding that, as explained at length above, the record does not show any aberrancy in the Veteran's response to the oncoming vehicle in this case. That said, the probative evidence shows that the Veteran did not have any impairment in his ability to drive. The February 2007 neuropsychological report showed that he was cleared for driving by his neurologist based on cognitive testing. Although the Veteran had very poor verbal memory at the time, he "performed well in the areas most related to driving." In this regard, he demonstrated average to well above average visuospatial ability and attention to visual detail. His scores on measures of motor speed and speed of information processing were slightly above average. He also performed in the average to above average range on most measures of attention, concentration, and visual tracking. He had a slow response time on one measure of visual tracking, but his accuracy was better than that of the normative group, and it was noted that he may have been more cautious in his response style to maximize accuracy. His speeded performances on several other measures fell in the above average range. "Overall, in terms of cognitive functioning, [the Veteran was] a good candidate to return to driving." The MTF records show that he passed the state's driving test, and in April 2007 was noted to be driving without problems. In the November 2020 brief, the appellant noted that the February 2007 and December 2007 neuropsychological evaluations that cleared the Veteran for driving were performed five years before his December 2012 fatal car accident. The record does not show a decline in the Veteran's cognitive functioning between 2007 and 2012 relevant to his ability to drive. As indicated in the February 2007 neuropsychological report, and confirmed by the October 2018 VA medical opinion, his poor ability to process verbal information was not a basis for finding impaired ability to drive, and he "performed well in the areas most related to driving." Moreover, there is probative evidence showing that the Veteran's cognitive functioning remained stable. Specifically, the April 2010 letter from the Veteran's treating physician at BAMC states that his post-treatment disease course had remained stable. While he was "not without treatment-related and disease-related side effects" and cognitive impairment, these effects and disability had "greatly stabilized." The Board here notes that the "DSM IV-Cognitive disorder" cited in the April 2010 letter does not indicate that he had cognitive impairment other than with regard to processing verbal information which, as discussed above, did not impair his driving ability. In addition, a February 2011 private neurological treatment record states that the Veteran was "doing very well" and had "no recent changes from his neurologic baseline." He continued to have some word finding difficulties and short-term memory problems, but these problems were "chronic issues and [were] unchanged." In sum, the evidence does not show cognitive decline between the Veteran's 2007 cognitive testing to assess his ability to drive and the 2012 fatal car accident; on the contrary, there is probative evidence in the form of the April 2010 letter from the Veteran's treating physician, and the February 2011 private neurological treatment record, showing that his condition stabilized and that he was "doing very well." The appellant also stated in the November 2020 brief that there was no evidence that the Veteran's "reaction time" was tested. However, the February 2007 neuropsychological testing report that evaluated his ability to drive states that his scores on measures of motor speed and speed of information processing were slightly above average, and that he had a slow response time on one measure of visual tracking. This report indicates that his ability to react in a timely manner to changing conditions on the road, including other cars, was tested. In any event, the fact that neuropsychological testing was performed to assess whether he was a candidate to drive indicates in itself that his "reaction time" was tested, as that would be essential to the ability to drive safely. The appellant has not shown that the cognitive testing of the Veteran was incomplete or performed in a deficient manner. The Board notes that with regard to anti-seizure medication, the MTF records reflect that he was started on Keppra around December 2006. A January 2007 entry reflects that he was tolerating it well with no complications. He was thus taking this medication at the time of the neuropsychological evaluation that cleared him for driving. As discussed above, subsequent records do not show a change in the Veteran's cognitive functioning with respect to his ability to drive. The April 2010 MTF physician's letter notes that the Veteran had side effects from treatment, but that these had stabilized. The Board has also considered the fact that the Veteran took the wrong road when he drove to the January 2008 VA appointment, causing him to be later than he wanted to be, although he was still on time. There is no indication that his taking the wrong road was related to his ability to drive safely and respond appropriately to changing road conditions, including the actions of other drivers. No such finding was suggested in the January 2008 VA treatment record or otherwise in the medical evidence of record. To the extent his taking the wrong road was related to cognitive impairment, the record states that he usually wrote directions down due to trouble remembering information so that "won't get lost like he did today." In other words, this record suggests he had driven to a location he did not normally go to, and that he was using his memory of the directions to guide him since he had not written them down. Accordingly, his taking the wrong road on that occasion does not support a finding that his driving ability was impaired. As found by the neurologist who assessed his ability to drive, and the October 2018 VA examiner, who is also a neurologist, the Veteran's impairment in processing verbal information did not impair his ability to drive. The February 2013 and December 2018 private medical opinions have little probative value with respect to the issue of whether the Veteran had a slow reaction time. In this regard, they conflict with the above-discussed treatment records showing that his performance was average to above average on most cognitive tests, including on speeded performances and tests designed to measure attention, concentration, and visual tracking, and that his scores made him a "good candidate" for driving. Therefore, as neither opinion accounts for the findings in these records, or is grounded itself in testing or examination of the Veteran, they have little or no probative value on that issue. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (holding that the probative value of a medical opinion comes from its reasoning, and that critical pieces of information from a claimant's medical history can lend credence to the opinion of a medical expert who considers them, and detract from the medical opinions of experts who do not). In addition, as indicated in Dr. Bower's February 2013 medical opinion that it "is possible that [the Veteran's] reaction time in instances that require[d] prompt reaction could be slowed" (emphasis added), these opinions are merely speculative, and as such carry little probative weight. See Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996). The Board finds that the private medical opinions are outweighed by the October 2018 VA medical opinion. That opinion is probative, as it represents the conclusion of a medical expert that is based on and consistent with the Veteran's treatment records, and is supported by an explanation that enables the Board to make an informed decision. In brief, the neuropsychologist concluded that although the Veteran's cognitive impairment and dementia resulting from the temporal lobe resection limited his ability to process verbal information, it did not affect cognitive areas related to his ability to drive. The October 2018 opinion outweighs the private medical opinions dated in February 2013 and December 2018, whose probative value is vitiated by their speculative nature and failure to account for the neuropsychological assessments showing that the Veteran generally performed average to above average on tests assessing cognitive areas related to his ability to drive. The appellant's statements that the Veteran had a slowed reaction time, and that this was a factor in the car accident, essentially stand on the same footing as the private medical opinions, which have little or no probative value, as explained above. Her statements must be discounted for the same reasons. Regarding her statement that the Veteran's anti-seizure medication contributed to slower thinking, the treatment records do not show such a finding. Moreover, even if that were the case, neurocognitive testing showed that the Veteran's ability to process information in areas related to driving was not affected, as found in the February 2007 neuropsychological assessment. The appellant's statements do not account for that evidence and are not otherwise supported by an independent rationale. As explained at length above, the preponderance of the evidence shows that to the extent the Veteran had slowed down thinking, it did not compromise his driving ability. Accordingly, the appellant's statements are not probative on that issue, and are outweighed by the October 2018 VA medical opinion and the neuropsychological testing reports. In addition, because the appellant is not shown to have a medical background or medical expertise, she is considered a lay person in the field of medicine. Therefore, her opinion that the Veteran's ability to respond to the oncoming vehicle was compromised due to his cognitive impairment is not competent evidence, as this is a complex determination that cannot be made based on lay observation alone, and thus requires medical evidence. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). This is evident from the fact that when physicians were determining whether the Veteran could drive safely, they performed cognitive testing to assess his ability to drive. Accordingly, the appellant's lay opinion is not probative on that issue. It is outweighed by the October 2018 opinion by the VA neuropsychologist. Accordingly, the preponderance of the evidence shows that the Veteran's ability to drive was not compromised by his service-connected cognitive impairment, including with respect to the ability to respond in a timely manner to changing road conditions such as the actions of other drivers. In any event, as explained above, the record does not show or suggest that the Veteran in fact responded in a slow or aberrant manner to the oncoming car that resulted in the fatal collision, even if his ability to timely process visuospatial information was generally impaired. But such impairment is not established, for the reasons just discussed. The parties to the JMR agreed that in its June 2019 decision, the Board erred by not addressing "whether the Veteran's service-connected cognitive disorder and dementia disabilities were a contributory cause of his death under 38 C.F.R. § 3.312(c)(3), which is applicable for a claimant with a service-connected disability [affecting] a vital organ rated at 100% disabling." The Board has considered the applicability of 38 C.F.R. § 3.312(c)(3), and finds that it does not support the claim in this case. The Veteran's service-connected resection of the left temporal lobe to treat cancer of the brain involved a vital organ, and was rated as 100 percent disabling. The April 2010 letter from his treating physician at BAMC notes that the Veteran's condition was stable, apart from side effects of the resection and ongoing medication. Nevertheless, the Board will assume it involved an active process. Accordingly, the Board assumes the Veteran had debilitation and general impairment of health due to his service-connected disability. See 38 C.F.R. § 3.312(c)(3). Still, there must be evidence that such debilitation was an actual factor in the Veteran's death. That determination, unlike the determination of whether the Veteran's cognitive impairment affected his driving such that it played a role in the car accident, does concern, and basically turns on, the biological mechanism of death. In essence, the issue is whether the Veteran would have succumbed to his injuries, or at least not succumbed to them so quickly or readily, had he not had the brain tumor and subsequent left temporal lobe resection. As the death certificate shows that he died within seconds of the accident due to multiple traumatic injuries, and as there is no evidence suggesting that the death would not have occurred, or would not have occurred so quickly had he not had the brain tumor and subsequent resection, the Board finds that the provisions of § 3.312(c)(3) do not alter the conclusion that his service-connected disabilities neither caused nor contributed substantially or materially to the cause of death. The circumstances of his death, namely a head on collision with another car driving at 80 miles per hour, are consistent with that conclusion. Although the Board's finding would remain the same in either case, the Board observes that the other driver also died as a result of the accident that same day. In sum, the Veteran's cognitive impairment with dementia did not cause or contribute to his death resulting from the motor vehicle accident. There is no indication that any of his other service-connected disabilities caused or contributed to that accident or his death. Rather, the evidence shows that the only cause of death was injuries sustained in the motor vehicle accident. Accordingly, as a service-connected disability was neither a principal nor a contributory cause of the Veteran's death, the criteria for service connection for the cause of his death are not satisfied. See 38 U.S.C. § 1310; 38 C.F.R. § 3.312. Because preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board is sorry for the appellant's loss, and regrets that it cannot render a favorable determination in this matter. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rutkin, 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.