Citation Nr: 21040257 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 16-09 388 DATE: July 2, 2021 ORDER Entitlement to service connection for diabetes mellitus type II (diabetes) is granted. Entitlement to service connection for diabetic retinopathy is granted. REMANDED Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. The evidence shows that the Veteran's diabetes is secondary to her service-connected hypothyroidism. 2. The evidence shows that the Veteran's diabetic retinopathy is secondary to her service-connected diabetes. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes have been met. 38 U.S.C. §§ 1110, 1131; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for diabetic retinopathy have been met. 38 U.S.C. §§ 1110, 1131; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1969 to July 1980, to include service at the Udorn Air Force Base (AFB), Thailand. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted a notice of disagreement in September 2013. The RO issued a statement of the case in January 2016. The Veteran submitted her substantive appeal (VA Form 9) in February 2016. The RO issued a supplemental statement of the case in October 2018. In her February 2016 substantive appeal, the Veteran requested a Board hearing before a Veterans Law Judge. However, in July 2019, she withdrew such request. 38 C.F.R. §§ 20.702 (e), 20.704(e). The Board observes that new relevant evidence was submitted following the October 2018 supplemental statement of the case. In April 2021, the Board advised the Veteran of this fact and that such evidence had not previously been considered by the RO. In May 2021, the Veteran submitted a waiver of RO jurisdiction and requested that the Board maintain jurisdiction of the appeal. The Board also notes that in August 2011, the Veteran submitted a request for reopening of a claim for service connection for diabetes. However, the Veteran's diabetes had not previously been considered for service connection. In April 1983, a rating decision was issued denying service connection for hypoglycemia. Although hypoglycemia is often associated with diabetes, it is a separate diagnosable condition. As such, the claim for service connection for diabetes was not a request for reopening of a final decision but was a new service connection claim. The Veteran contends that her diabetes, diabetic retinopathy, and hypertension are related to herbicide exposure during her service in Thailand. The Veteran has stated that she was at Udorn AFB from June 1974 to December 1975, along with her husband, on the Husband and Wife Deployment Program. She also stated that, as a Dental Technician, she regularly crossed the perimeter on foot or on her bike to go to the Dental Clinic, as well as crossing the perimeter to provide humanitarian aid in the villages. She has also explained that she and her husband would jog, walk, and run the path of the sprayed perimeter. They had lunch, dinner and duty along with others at the perimeter. Her husband worked at the air terminal and they would walk the exposed area. The Veteran also contends that her diabetes, diabetic retinopathy, and hypertension were caused or aggravated by her service-connected hypothyroidism and, in May 2020, submitted articles to support this contention. Service Connection Generally, to establish service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 131516 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 U.S.C. §§ 1131; 38 C.F.R. § 3.303(d). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 U.S.C. §§ 1131; 5107; 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated (permanently worsened in severity beyond its natural progress) by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 44849 (1995). 1. Entitlement to service connection for diabetes 2. Entitlement to service connection for diabetic retinopathy As an initial matter, the Board recognizes that the medical record establishes that the Veteran has diagnoses of diabetes and diabetic retinopathy. Therefore, the first requirement for service connection has been met. It is recognized that the Veteran's primary contention is that her diabetes and diabetic retinopathy should be service connected because she had herbicide agent exposure while being stationed at Udorn AFB, Thailand, but herbicide agent exposure has not yet been conceded. Nonetheless, the evidence supports a grant of service connection for diabetes and diabetic retinopathy as secondary to her service-connected hypothyroidism. In April 2021, the Veteran was afforded a VA examination in relation to her claim for service connection for diabetic neuropathy and the examiner considered the relationship between hypothyroidism and diabetes. The examiner opined that the Veteran's diabetic neuropathy was at least as likely as not caused by the service-connected hypothyroidism because medical literature shows a correlation between hypothyroidism and increased risk to acquire diabetes in statin users and nonusers regardless of statin use. As such, the examiner essentially determined that it is at least as likely as not that the Veteran's diabetes was caused by the service-connected hypothyroidism. The Board finds the April 2021 VA examination to be the most probative evidence of record regarding the relationship between hypothyroidism and diabetes as there is no other evidence of record considering such a relationship. Therefore, service-connection for diabetes is established as secondary to hypothyroidism. Furthermore, as service-connection for diabetes has been established, service-connection for diabetic retinopathy is also established because diabetic retinopathy, as the diagnosis indicates, is a direct result of the Veteran's diabetes. Therefore, the diabetic retinopathy was proximately caused by service-connected diabetes. Accordingly, service connection is warranted for diabetes and diabetic retinopathy. REASONS FOR REMAND Entitlement to service connection for hypertension is remanded The VA has the duty to make reasonable efforts to assist a claimant in securing evidence necessary to substantiate their claim for VA benefits. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). As discussed above, the Veteran has expressed that she was exposed to herbicide agents on the perimeter of the Udorn AFB. She has submitted multiple statements regarding facts potentially supporting her contention. However, no request has been made to the Joint Service Record Research Center (JSRRC), now the U.S. Department of Army, Records Management and Declassification Agency (RMDA) to determine if the Veteran's in-service herbicide agent exposure could be verified. In September 2013, the Veteran specifically asked that a request to the JSRRC be made in order to make a formal finding. In May 2018, the Veteran requested that the VA assist in obtaining the Army Daily Unit Log showing her exit and re-entry over the sprayed tactical herbicide perimeter. No assistance has been provided in that respect. The Veteran has also stated that she was at the Udorn AFB from June 1974 to December 1975. The evidence of record only establishes that the Veteran was at Udorn AFB from June 1975 to December 1975 based on a performance report. However, the performance report from June 1974 to December 1974 was removed from the case file. See Military Personnel Record, November 1, 1976. Had it not been removed such evidence could have established the Veteran's presence at Udorn AFB during that period. As the Veteran and her husband were stationed at Udorn AFB together, on the Husband and Wife Deployment Program, it is possible that information in her ex-husband's military personnel records could support her contention that she was at Udorn AFB from June 1974 to December 1975. No attempt to obtain records in support of the Veteran's statements has been made. As the RO did not make any attempts to obtain the information referenced by the Veteran that could support her contention that she was exposed to herbicide agents while stationed at Udorn AFB, the VA duty to assist was not met. Additionally, as part of the duty to assist, the VA must obtain an examination in service connection claims when there is an indication that the current disability may be associated with the Veteran's service and there is a lack of sufficient evidence to decide the claim. See McClendon v. Nicholson, 20 Vet. App. 79, 83 (2006). In McClendon, the Court found that the VA Secretary must provide a VA medical opinion when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing than an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of disability may be associated with service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. The record establishes that the Veteran has a current diagnosis of hypertension. Furthermore, in May 2020, a medical article was submitted regarding the relationship ship between thyroid hormone and hypertension. Therefore, the record establishes a potential connection between the Veteran's service-connected hypothyroidism and hypertension. A March 2013 medical report of record also indicated that due to the Veteran's diabetic retinopathy she should maintain tight glycemic and blood pressure control. This suggests that the Veteran's diabetes may also have a relationship to her hypertension. Based on the foregoing, the record indicates that the Veteran's hypertension could be related to her service-connected hypothyroidism and diabetes, but a VA hypertension examination has not yet been provided. As such, a determination on service-connection cannot be made. Therefore, remand is necessary to afford the Veteran a VA hypertension examination. Accordingly, remand is warranted for further development. The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran submit the names and addresses of any and all health care providers who have provided treatment for her hypertension. After acquiring this information and obtaining any necessary authorization, the AOJ should associate these records with the claims file. The AOJ should also obtain and associate with the claims file any outstanding VA treatment records. 2. The Veteran should be afforded the opportunity to provide witness statements, including a statement from her ex-husband, regarding her period of service at the Udorn AFB, Thailand, as well as her proximity to the perimeter. Then, contact all appropriate service department(s) regarding verification of the Veteran's herbicide agent exposure. To include research of her ex-husband's military record, for corroboration of her statements. In so doing, the RO must send a request to the RMDA. 3. After completing the foregoing development, the Veteran should be scheduled for an examination with an appropriate VA clinician for the issuance of a medical opinion as to the nature and etiology of her hypertension. The clinician should thoroughly review the Veteran's entire claims file, including a copy of this Remand. Any evaluations, studies, or tests deemed necessary by the examiner should be accomplished and any such results must be included in the examination report. The examiner should be advised that the Veteran is competent to attest to factual matters of which she has first-hand knowledge, including observable symptomatology. Based on the examination and review of the record, the examiner is asked to provide an opinion whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran's diagnosed hypertension (1) is related to an event, injury or disease incurred in service; (2) was caused by her service-connected hypothyroidism or diabetes; or (3) was aggravated by her service-connected hypothyroidism or diabetes. The term "aggravation" is defined for legal purposes as a chronic worsening of the underlying condition beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability (i.e., a baseline) before the onset of the aggravation. A complete rationale for any opinion expressed must be provided. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 4. After completing the requested actions, and any additional action deemed warranted, readjudicate the claim on appeal. If the benefit sought on appeal remains denied, provide a supplemental statement of the case to the Veteran and her representative and afford them an opportunity to respond. Then, return the case to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Temple, 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.