Citation Nr: 22017944 Decision Date: 03/27/22 Archive Date: 03/27/22 DOCKET NO. 15-22 872 DATE: March 27, 2022 ORDER Service connection for an eye disability is denied. Service connection for hypertension is denied. FINDINGS OF FACT 1. The Veteran's eye disability did not arise in and is not otherwise etiologically related to any period of active duty for training, inactive duty for training, or active duty service. 2. The Veteran's hypertension did not arise in and is not otherwise etiologically related to any period of active duty for training, inactive duty for training, or active duty service. CONCLUSIONS OF LAW 1. The criteria for service connection for an eye disability have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from December 1986 to December 1988. The Veteran then served in the Naval Reserve from December 1988 to May 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran presented sworn testimony at a hearing before the undersigned Veterans Law Judge (VLJ) in January 2020. This case was previously remanded by the Board in a March 2020 decision for additional development. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). The term "active military, naval, or air service" includes active duty, any period of active duty for training during which the individual was disabled or died from a disease or injury incurred in or aggravated in the line of duty, and any period of inactive duty training during which the individual was disabled or died from an injury incurred in or aggravated in the line of duty. 38 U.S.C. § 101(24). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Service connection for an eye disability The Veteran contends that her eye disability had its onset while she was in active duty while a member of the Naval Reserves, following her time in the Navy. The Veteran was provided a VA eyes examination in May 2013 in which she was diagnosed with recurrent iritis, with past reports of intermittent episodes of "redness, light sensitivity, pain and inflammation" of the right eye. The VA examiner opined that the recurrent iritis was at least as likely as not incurred in service with an episode documented in May 2000. In the March 2020 Board decision, the Board noted that the Veteran's time in the Naval Reserves is shown to have multiple periods of active duty for training (ADT) and inactive duty for training (IDT) and it was unclear whether the onset and complaints of iritis occurred in periods of time where the Veteran was either in ADT or IDT. The Board acknowledged that the VA examiner who conducted the May 2013 VA examination for the eyes provided a positive nexus opinion as to onset during Naval Reserve duty; however, complete military personnel records and service treatment records were needed to distinguish whether the disability was incurred in periods of active duty or inactive duty. Therefore, the claim was remanded to obtain a new VA examination and medical opinion to address onset and etiology of the Veteran's eye disability. The Veteran was afforded a VA examination of the eyes in September 2021 in which she was diagnosed with uveitis of both eyes, scleritis of the right eye and episcleritis of the left eye. The onset date of the uveitis was in 2000 for the right eye and 2002 for the left eye, which was treated with steroid eye drops. The uveitis will flare up randomly during the year in one or both eyes and Veteran reported current symptoms of redness and foreign body sensation of the left eye and no symptoms of the right eye. Veteran was diagnosed with an ophthalmologist in 2002 with right eye scleritis in 2002, was given ocular injections for the issue and no injections since the initial onset. The VA examiner opined that after review of the Veteran's claims file including the entrance and exit examinations, the ocular diagnoses for the claimed eye conditions were made during time of inactive duty per the Statement of Service for Naval Reserve Retirement. The examiner concluded that none of the eye conditions are due to any in-service injury, event, or illness. The Veteran's service treatment records indicate that she reported developing an eye condition in February 2002, diagnosed with scleritis, and was treated with heavy doses of prednisone to reduce the swelling. As of June 2002, the problem had subsided. See Service Treatment Records. March 2002 medical records also indicate the Veteran complained of painful red eye and was diagnosed with scleritis. In a January 2004 Annual Certificate of Physical Condition, the Veteran stated she has been under the care of an eye doctor because she was being taken off her prednisone drops for her eyes. Further, in an April 2007 letter, an ophthalmologist stated that Veteran has been seeking treatment for recurrent uveitis in both eyes for the past five years and the condition was currently stable with no evidence of inflammation. The Veteran's complaints, that are documented in the claims file, regarding eye issues during her Naval Reserve service arise in May 2000, February 2002 to June 2002, and recurrent episodes of uveitis between March 2002 and April 2007. Per the Veteran's Statement of Service for Naval Reserve Retirement, the Veteran did not have any active duty service between June 1989 to June 2006. The Veteran gathered 0 points for ADT between June 1999 and June 2002, 30 ADT points from June 2002 to June 2003, 13 ADT points from June 2003 to June 2004, 15 ADT points from June 2004 to June 2005 and 19 ADT points from June 2005 to June 2006. The Veteran has between 59 and 72 points for inactive duty training for each yearly period between June 1999 and June 2006. These credentials are also verified in an Annual Statement of Service History in the Veteran's file from August 1999. The Board finds, however, that the contemporaneous medical evidence regarding the Veteran's claimed eye conditions weigh against a finding that she incurred an eye condition in and period of active duty service or due to any period of active duty for training or inactive duty for training. There are relatively few pieces of evidence that determine the exact periods of Veteran's ADT and IDT. Ultimately, the record simply does not contain any competent and credible evidence indicating that the Veteran's onset of her eye conditions began during her period of ADT or IDT during the periods in question, that appear to be May 2000 and February 2002 to April 2007. The Veteran's lay statements regarding the onset of her symptoms are not competent evidence linking an eye disability to periods of credible ADT or IDT eligible for service connection. The Court has made clear that VA benefits can only be granted when there has been service department verification that a VA claimant served in the United States Armed Forces. Duro v. Derwinski, 2 Vet. App. 530, 532 (1992). The Court further explained that VA is "prohibited from finding, on any basis other than a service department document, which VA believes to be authentic and accurate, or service department verification, that a particular individual served in the U.S. Armed Forces." Id. While the holding of the Court in Duro only mentioned verification of active duty service, it subsequently clarified that the requirement of verification of service by official service department records also applies to ACDUTRA and INACTDUTRA. Cahall v. Brown, 7 Vet. App. 232, 237 (1994). In other words, VA can only find that an individual was serving on active duty for training or inactive duty for training when such service is documented in official service department records. Id. The Board finds that there are no service department records verifying that Veteran was on a period of ACTDUTRA or INACTDUTRA at the time of her complaints, treatment or diagnoses of any eye disability. The Naval Reserve retirement points history statement that are in the claims file do not determine whether an eye disability was manifested during periods in which the Veteran was serving on active duty for training or inactive duty for training; the personnel records do document the fact the Veteran was not on active duty service since June 1989. On the contrary, the September 2021 VA examiner who provided a negative medical nexus opinion possesses medical training that renders the examiner competent to opine on the medically complex question of whether and when the Veteran demonstrated the symptomatology of an eye disability. The Board finds that the September 2021 VA examiner's opinion is substantially probative regarding the question of whether the Veteran's eye disability had its onset during any period of service. As there is simply no competent service department evidence that the Veteran was serving on ACDUTRA or INACDUTRA in the periods when the Veteran's eye disability appear to have manifested, and there is otherwise no competent evidence linking the Veteran's eye disability to any confirmed periods of ACDUTRA, INACDUTRA, or active duty service, the Board finds that the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for an eye disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Service connection for hypertension The Veteran contends that her hypertension condition had its onset while she was in active duty while a member of the Naval Reserves, following her time in the Navy. The Veteran was provided a VA hypertension examination in May 2013 in which she was diagnosed with hypertension with an onset in the early 2000s; the Veteran stated at the time at her hypertension was stable on medication which consisted of lisinopril and metoprolol. The VA examiner opined that the Veteran has high blood pressure record in the military and had no history of high blood pressure before service, so it as more likely than not the condition was incurred in or caused by the time in the Naval Reserves. In the March 2020 Board decision, the Board noted that the Veteran's time in the Naval Reserves is shown to have multiple periods of active duty for training (ADT) and inactive duty for training (IDT) and it was unclear whether the onset and complaints of hypertension occurred in periods of time where the Veteran was either in ADT or IDT. The Board acknowledged that the VA examiner who conducted the May 2013 VA examination for hypertension provided a positive nexus opinion as to onset during Naval Reserve duty; however, complete military personnel records and service treatment records were needed to distinguish whether the disability was incurred in periods of active duty or inactive duty. Therefore, the claim was remanded to obtain a new VA examination and medical opinion to address onset and etiology of the Veteran's hypertension disability. The Veteran was provided a VA examination for hypertension in June 2020, in which she was diagnosed with hypertension, with a date of diagnosis in 2007. The Veteran reported developing high blood pressure in the 2000s, first seeking medication for the condition in 2012, and she was noted to have hypertension with microalbuminuria in 2019. The VA examiner concluded that the Veteran's documented Previous Medical History at the VA states she was diagnosed with hypertension in 2007 and no Line of Duty Statement from her period of service with the Naval Reserves showed treatment or diagnoses of hypertension. The examiner also indicated that the Veteran's blood pressure readings during this period do not meet diagnostic criteria for hypertension and there is no documentation of treatment of hypertension with medication until 2012. The examiner opined that there is no established medical nexus relating the Veteran's hypertension to service. The Veteran was also afforded a VA heart conditions examination in June 2020 in which she was diagnosed with valvular heart disease with a diagnosis in 2013; the Veteran was noted to have a heart murmur in 2012, had an echocardiogram in April 2013 which noted borderline cardiomegaly. The condition has been stable since onset. In a December 2021 Addendum, the VA examiner opined that there is no evidence of complaints, diagnoses, or medical treatment for valvular heart disease while Veteran was in service. While the Veteran currently has a diagnosis of valvular heart disease, the examiner opted to provide a negative nexus opinion as there is no evidence that Veteran's service causes the heart disease, and no nexus could be established linking the condition to Veteran's service. Per the Veteran's Statement of Service for Naval Reserve Retirement, the Veteran did not have any active duty service between June 1989 to June 2006. The Veteran gathered 0 points for ADT between June 1999 and June 2002, 30 ADT points from June 2002 to June 2003, 13 ADT points from June 2003 to June 2004, 15 ADT points from June 2004 to June 2005 and 19 ADT points from June 2005 to June 2006. The Veteran has between 59 and 72 points for inactive duty training for each yearly period between June 1999 and June 2006. These credentials are also verified in an Annual Statement of Service History in the Veteran's file from August 1999. The Board finds, however, that the contemporaneous medical evidence regarding the Veteran's claimed hypertension weigh against a finding that she incurred a hypertension disability in a period of active duty service or due to any period of active duty for training or inactive duty for training. There are relatively few pieces of evidence that determine the exact periods of Veteran's ADT and IDT. Ultimately, the record simply does not contain any competent and credible evidence indicating that the Veteran's onset of her hypertension began during her period of ADT or IDT during the periods in question, that appear to be the "early 2000s." The Veteran's lay statements regarding the onset of her symptoms are not competent evidence linking hypertension to periods of credible ADT or IDT eligible for service connection. The Court has made clear that VA benefits can only be granted when there has been service department verification that a VA claimant served in the United States Armed Forces. Duro v. Derwinski, 2 Vet. App. 530, 532 (1992). The Court further explained that VA is "prohibited from finding, on any basis other than a service department document, which VA believes to be authentic and accurate, or service department verification, that a particular individual served in the U.S. Armed Forces." Id. While the holding of the Court in Duro only mentioned verification of active duty service, it subsequently clarified that the requirement of verification of service by official service department records also applies to ACDUTRA and INACTDUTRA. Cahall v. Brown, 7 Vet. App. 232, 237 (1994). In other words, VA can only find that an individual was serving on active duty for training or inactive duty for training when such service is documented in official service department records. Id. The Board finds that there are no service department records verifying that Veteran was on a period of ACTDUTRA or INACTDUTRA at the time of her complaints, treatment or diagnoses of hypertension. The Naval Reserve retirement points history statement that are in the claims file do not determine whether a hypertension condition was manifested during periods in which the Veteran was serving on active duty for training or inactive duty for training; the personnel records do document the fact the Veteran was not on active duty service since June 1989. On the contrary, the December 2021 VA examiner who provided a negative medical nexus opinion possesses medical training that renders the examiner competent to opine on the medically complex question of whether and when the Veteran demonstrated the symptomatology of a hypertension disability. The Board finds that the September 2021 VA examiner's opinion is substantially probative regarding the question of whether the Veteran's hypertension had its onset during any period of service. (Continued on the next page) As there is simply no competent service department evidence that the Veteran was serving on ACDUTRA or INACDUTRA in the periods when the Veteran's hypertension disability appear to have manifested, and there is otherwise no competent evidence linking the Veteran's hypertension disability to any confirmed periods of ACDUTRA, INACDUTRA, or active duty service, the Board finds that the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for hypertension is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zarar Ahmed, Attorney Advisor 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.