Citation Nr: 21029532 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 15-41 078A DATE: May 13, 2021 REMANDED Entitlement to service connection for cause of death is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1943 to December 1945. The Veteran died in January 1980. The appellant is the Veteran's surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) that denied the appellant's claim of service connection for the cause of the Veteran's death. In July 2014 the appellant filed a notice of disagreement (NOD) and in October 2015 the RO issued a statement of the case (SOC). In November 2015 the appellant filed a substantive appeal (via VA Form 9). In July 2019 the Board remanded the appellant's claim for further evidentiary development, specifically, to determine if the Veteran's service-connected anxiety disorder, hepatitis, and hemorrhoids and/or in-service treatment for Dengue fever and ulcers substantially or materially contributed to the Veteran's death. As will be discussed below, the RO did not substantially comply with the July 2019 remand instructions and another remand is required. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for the cause of the Veteran's death Dependency and Indemnity Compensation benefits are payable to the surviving spouse of a Veteran if the Veteran died from a service-connected disability. 38 U.S.C. § 1310(a); 38 C.F.R. § 3.5(a)(1). In order to establish service connection for the cause of a Veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 C.F.R. § 3.312(a). In order to constitute the contributory cause of death, it must be shown that the service-connected disability contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. 38 C.F.R. § 3.312(c)(1). The Veteran's death certificate lists his immediate cause of death as coronary occlusion due to or as a consequence of arteriosclerotic heart disease. On the November 2013 Application for Dependency and Indemnity Compensation or Death Pension by a Surviving Spouse or Child (VA Form 21-534EZ) the appellant stated that the Veteran contracted dengue fever in service which led to his heart problems and caused his death. In March 2017 letters, the Veteran's son and daughter stated that the Veteran endured shrapnel injuries from a bomb in service which led to him being discharged. In a June 2019 informal hearing presentation (IHP) the appellant, through her representative, stated that the Veteran died of ischemic heart disease which was caused by his service-connected anxiety disorder. The appellant's representative expressed that the Veteran's anxiety disorder would best be characterized as posttraumatic stress disorder (PTSD) even though he was not diagnosed with PTSD during his lifetime. The appellant's representative then cited to treatise articles linking PTSD to coronary artery disease. The appellant's representative also noted that the Veteran was service connected for hepatitis which could have caused his heart disease either directly or in combination with his service-connected anxiety disorder. In July 2019 the Board directed the RO to obtain a medical opinion from an appropriate medical professional as to whether it was at least as likely as not that the Veteran's service-connected anxiety, hepatitis and hemorrhoids, and/or his in-service treatment for Dengue Fever and ulcers contributed substantially or materially to the Veteran's death. The Board specifically directed the medical professional to address the literature cited in the June 2019 IHP regarding the Veteran's undiagnosed PTSD. In February 2020 a VA physician opined it is less likely than not that hepatitis, dengue fever, hemorrhoidectomy, PTSD, and ulcers substantially or materially contributed to the Veteran's death as his medical records do not show significant residuals from his these conditions and they are separate entities and medically unrelated to arteriosclerotic heart disease. The February 2020 VA opinion did not substantially comply with the July 2019 remand instructions because the VA physician did not discuss the articles mentioned in the June 2019 IHP. Stegall, 11 Vet. App. at 271. Therefore, another remand is warranted to provide an adequate opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide an examination or obtain a medical opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: 1. Obtain a medical opinion from an appropriate clinician to opine whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected hepatitis and hemorrhoids and/or the in-service treatment for Dengue Fever and ulcers contributed substantially or materially to the Veteran's death. The clinician must provide a complete rationale upon which his or her opinion is based and must include a discussion of the medical principles as applied to the medical evidence and facts used, including lay statements, in establishing his or her opinion. 2. Obtain a medical opinion from a psychiatrist to opine whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected anxiety disorder contributed substantially or materially to the Veteran's death. In formulating the opinion, the psychiatrist must address the literature cited in the June 2019 IHP. The psychiatrist must also address the appellant's contention that the Veteran had undiagnosed PTSD and that his anxiety disorder would be better characterized as PTSD. The psychiatrist must provide a complete rationale upon which his or her opinion is based and must include a discussion of the medical principles as applied to the medical evidence and facts used, including lay statements, in establishing his or her opinion. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James R. Miller, Associate 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.