Citation Nr: 21032801 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 16-23 062 DATE: May 28, 2021 ORDER Entitlement to service connection for the cause of the Veteran's death is denied. FINDINGS OF FACT 1. The Veteran died in August 2013, and his death certificate listed the principal cause of death as hypertensive cardiovascular disease. Diabetes mellitus was listed as a significant condition contributing to death. 2. At the time of the Veteran's death, he was service connected for schizophrenia, paranoid type. 3. The most probative evidence does not establish that a service-connected disability caused or contributed materially or substantially to the Veteran's death. CONCLUSION OF LAW A service-connected disability did not cause death or contribute substantially or materially to death. 38 U.S.C. §§ 1131, 1310, 5107; 38 C.F.R. § 3.312. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active military service from September 1975 to April 1976. Unfortunately, he died in August 2013. The appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The appellant requested a Board hearing, which was scheduled in December 2018, but she failed to appear. See Board decision, January 2019. Therefore, her request is considered withdrawn. This matter was previously before the Board in January 2019, March 2020, and March 2021. In January 2019, the issue was remanded for further development, to include obtaining an opinion regarding if the medication taken for the Veteran's service-connected schizophrenia contributed to the Veteran's death, to include causing obesity which caused his hypertensive cardiovascular disease. In March 2020, the issue was remanded for a VA medical opinion to address whether the cause of the Veteran's death (hypertensive cardiovascular disease) was aggravated by his service-connected schizophrenia. In March 2021, the issue was remanded to mail the July 2020 Supplemental Statement of the Case to the appellant's last known address. The Supplemental Statement of the Case was re-mailed in April 2021. Further attempts were made to contact the appellant via telephone in April and May 2021, but to no avail. The matter now returns to the Board. Entitlement to service connection for the Veteran's cause of death VA death 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), 3.312. 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). To be considered a principal cause of death, a service-connected disability must have been singly or jointly with some other condition the immediate or underlying cause of death or have been etiologically related to the cause of death. For a service-connected disability to be a contributing cause, it must have substantially or materially contributed to a veteran's death; it is not sufficient to show that it casually shared in producing death, but rather there must be a causal connection. A contributory cause of death is inherently one not related to the principal cause. 38 U.S.C. § 1310; 38 C.F.R. § 3.312(b), (c). In determining whether the disability that resulted in the death of a veteran was the result of active service, the laws and regulations pertaining to basic service connection apply. 38 U.S.C. § 1310. Generally, service connection for a disability requires the following: (1) existence of a current disability, (2) existence of a disease or injury during active duty service, and (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Upon weighing the evidence of record, the Board finds that the preponderance of the evidence is against the claim of service connection for the cause of the Veteran's death. The Certificate of Death lists the principal cause of death as hypertensive cardiovascular disease. The death certificate also lists diabetes mellitus as a significant condition contributing to death. At the time of his death, the Veteran was service connected for schizophrenia, paranoid type. Service connection for schizophrenia was established since February 1982. The Veteran was not in receipt of service connection benefits for hypertensive vascular disease or diabetes mellitus during his lifetime. The appellant has asserted that service connection is warranted for the cause of the Veteran's death, as his life-long schizophrenia placed a strain on his heart that led to his untimely death. See NOD, May 2014. Additionally, she has contended that the Veteran's service-connected schizophrenia and related medication, specifically his prescribed Risperidone, was a contributory cause of death. See VA Form 9, May 2016. She also has contended that his schizophrenia made him more prone to physical neglect, such as not being physically active due to his depressed state, which may have led to or aggravated his high blood pressure and cardiovascular disease. See February 2016 correspondence. In support of her contentions, she submitted the following articles in February 2016 correspondence: Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder; Excess Mortality, Causes of Death and Life Expectancy in 270,770 Patients with Recent Onset of Mental Disorders in Denmark, Finland and Sweden; Increased mortality in schizophrenia due to cardiovascular disease a non-systematic review of epidemiology, possible causes, and interventions; and Life Expectancy and Death by Diseases of the Circulatory System in Patients with Bipolar Disorder or Schizophrenia in the Nordic Countries. In addition, her correspondence included a copy of the Veteran's autopsy, which revealed severe right and left ventricular cardiac hypertrophy, severe atherosclerotic coronary disease with 80 percent stenosis of the right coronary artery, and old and recent myocardial infarcts. The Veteran's cause of death was hypertensive cardiovascular disease with sudden cardiac death, with the manner of death listed as natural. Although the Veteran had precancerous and cancerous lesions, it was less likely that these lesions contributed to his death. See Autopsy Report, Page 12. In March 2016, a VA medical examiner opined that it was less likely than not that the Veteran's death was proximately due to or the result of his service-connected condition. The rationale provided was that the medical evidence did not support the appellant's contention that the Veteran's service-connected schizophrenia placed a strain on his heart that led to his untimely death. The medical evidence did support a prolongation of his QT interval on the EKG after beginning Risperidone, however, that is not a "strain on his heart so to speak." The death certificate noted hypertensive cardiovascular disease, with no medical records to confirm/deny an arrhythmia as the cause of the death. A June 2016 VA medical opinion found that the Veteran's death was less likely than not caused by his service-connected schizophrenia. The examiner noted a review of the appellant's statements and articles supplied, in addition to the autopsy and claims file. The rationale provided was that the Veteran suffered an acute myocardial infarction shortly prior to his death and had evidence of old myocardial infarct. The Veteran's autopsy report notes he suffered a sudden cardiac death, and most arrhythmias are not caused by or the result of a condition defect as would be related to his first degree AV block or prolonged QT, but is more often due to arrhythmogenic foci near old scars distant from the conduction system which induce electrical instability within the myocardium. The examiner further noted that current medical evidence is not sufficient to support a causal relationship between schizophrenia and hypertensive coronary artery disease (CAD). The fact that there may be links does not rise to the level of at least as likely as not causal or significant aggravating factor in the development of a disease. Further, having an elevated mortality rate in individuals with schizophrenia more than the general population does not support a causal relationship with a specific health condition. The examiner also noted that the appellant reported the Veteran was self-neglectful. Although unfortunate, it does not cause cardiac disease or hypertension. The Veteran was receiving care from the VA for hypertension and was offered the MOVE program to help with diet and exercise. Regarding an opinion on aggravation, the examiner opined that it would be mere speculation to attempt to determine if the Veteran's death related to CAD/hypertensive vascular disease with sudden cardiac death was chronically aggravated beyond normal progression. The Veteran had a positive family medical history of hypertension and had elevated cholesterol. He was on medication with potential metabolic effects. The degree of their effects as to cause or chronically aggravate the development or progression of hypertension/CAD could only be determined by mere speculation. Pursuant to the January 2019 Board remand, a December 2019 VA medical examiner opined that the Veteran's obesity was not proximately due to or the result of his schizophrenia, paranoid type. After a thorough review of the Veteran's claims folder and medical records, the examiner found there was no research to support the contention that the Veteran's medical/physical conditions that caused his death were the result of his mental/psychiatric condition. In addition, the examiner opined that it was less likely than not that the medication taken for the Veteran's service-connected schizophrenia contributed substantially or materially, that it combined to cause death, or that it aided or lent assistance to the production of death, to include causing obesity which caused his hypertensive cardiovascular. In July 2020, an addendum medical opinion was provided, finding that it was less likely than not that the Veteran's diabetes, hypertensive cardiovascular disease, or obesity were aggravated beyond their natural course due to schizophrenia or medications used in the treatment of schizophrenia. The rationale provided was that there was no mechanism by which schizophrenia would directly impact or aggravate diabetes, obesity, or hypertensive cardiovascular disease. The Veteran's cause of death was given as hypertensive cardiovascular disease with contribution from diabetes mellitus. The examiner noted that medication review does not show medications that would contribute to the cause of death. Risperidone has been associated with QT wave changes. If related to the cause of death, an arrhythmia would have been evident and as noted on the prior opinion, there is no evidence to support an arrhythmia occurring proximate to or at death. ST changes noted at the same time, were more likely than not, due to the cardiovascular disease itself. The examiner further noted that records regarding the events at death, or near death, were not available. A review of the Veteran's claims file, including cause of death and pertinent post-service treatment records, including those related to schizophrenia and associated medications was noted. The Veteran's service treatment records are negative for complaints of, treatment for, or diagnosis of hypertensive cardiovascular disease or diabetes mellitus, and the Veteran was only service connected for schizophrenia at the time of his death. There is no probative evidence tending to show that the Veteran's death was related to an event, injury, or disease in service. Additionally, to reasonably raise the theory of secondary service connection via obesity as an intermediate step, there must be some evidence in the record that draws an association or suggests a relationship between the veteran's obesity, or weight gain resulting in obesity, and a service connected disability. Conversely, incidental references to obesity, or weight gain resulting in obesity, are insufficient to reasonably raise this theory of entitlement. Garner v. Tran, 33 Vet. App. 241 (2021). Here, both the December 2019 and July 2020 VA opinions found that the Veteran's obesity was less likely than not related to, or aggravated by, his service-connected schizophrenia. The Board has explored every possible avenue to allow compensation for the cause of the Veteran's death; however, the evidence is against the claim. Here, the Veteran was service connected only for schizophrenia at the time of his death. The VA examiners in March 2016, June 2016, December 2019, and July 2020 all found that the service-connected condition did not cause or contribute to the Veteran's death, either on a direct or secondary basis. Given the explanations provided, and the fact that the examiners clearly considered all available relevant evidence and facts, the Board finds that these examinations provide an adequate basis for consideration of the issue of whether the Veteran's service-connected schizophrenia caused or contributed materially to his death. Accordingly, the Board finds that the competent medical evidence does not support a finding that the service-connected schizophrenia was either a principal or contributory cause of the Veteran's death. The competent evidence does not show that the service-connected disability contributed substantially or materially to the Veteran's death; combined to cause his death; or aided or lent assistance to the production of death. Significantly, a causal connection has not been demonstrated. 38 C.F.R. § 3.312(c)(1). The Board recognizes that the appellant sincerely believes that the Veteran's service-connected schizophrenia contributed to his death. However, there is no indication in the record that the appellant has the medical training and expertise necessary to determine the cause of the Veteran's death. As a lay person, she is not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). In addition, although the appellant mentioned in May 2014 correspondence she would be obtaining a medical opinion from a cardiologist to support her claim, no such opinion has been provided to date. Similarly, the appellant's contentions regarding side effects to a medication that she believes may have contributed to his death is less probative than the VA medical opinion directly discussing the specifics of the Veteran's case, including the specific medication she formerly discussed. The most probative evidence of record demonstrates that it is less likely than not that the Veteran's service-connected schizophrenia, including associated behaviors and medication, caused or contributed to the Veteran's death. The Board is sympathetic to the appellant's loss and is appreciative of the Veteran's honorable service. Nevertheless, the probative evidence of record fails to demonstrate that the Veteran's hypertensive cardiovascular disease or diabetes mellitus were related to his military service. Further, the record is silent for competent lay or medical evidence to support the secondary theories of service connection. As the preponderance of the competent evidence fails to show that a service-connected disability caused or substantially contributed to his death, service connection for the cause of the Veteran's death is denied. 38 U.S.C. § 5107(b). Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Krista Johnson, 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.