VARICOSE VEINS

Summary

The veteran, who served from June 1975 to October 1977, appeals the denial of service connection for vein problems, blood poisoning, and feet blisters, as well as compensation under 38 U.S.C. § 1151 for residuals of surgery to remove a giant cell tumor of the right wrist. The Board denied the claims for vein problems, blood poisoning, and feet blisters, finding no current diagnosis or residuals during the appeal period. While service treatment records showed in-service feet blisters, a subsequent VA examination found no current abnormalities or functional limitations. The Board found the examiner's opinion probative, concluding no current or past residuals of the blisters were associated with service. The claim for § 1151 compensation was also denied, as the Board found the additional disability from VA surgeries was not proximately caused by VA fault or an unforeseeable event, citing persuasive opinions from VA and independent medical examiners. The Board noted that while the veteran experienced additional disability, the fault and foreseeability elements were not met. The case was remanded for service connection for a giant cell bone tumor of the right radius, tremors, and an acquired psychiatric disorder. For the tumor and tremors, the Board noted evidence of aviation fuel exposure and requested an opinion on whether the condition is related to in-service injury or event. For the psychiatric disorder, the remand seeks to determine if the condition preexisted service or was aggravated by it, considering prior opinions and evidence of childhood trauma.

Rationale

No current diagnosis of vein problems; No residuals during appeal period; Claim denied due to lack of current diagnosis

Full Decision Text

Citation Nr: 19196990
Decision Date: 12/31/19	Archive Date: 12/31/19

DOCKET NO. 14-35 493
DATE: December 31, 2019

ORDER

Entitlement to service connection for vein problems is denied.

Entitlement to service connection for blood poisoning is denied.

Entitlement to service connection for feet blisters is denied.

Entitlement to compensation under 38 U.S.C. § 1151 for residuals of surgery to remove giant cell tumor of right wrist is denied.

REMANDED

Entitlement to service connection for giant cell bone tumor of the right radius is remanded.

Entitlement to service connection for tremors, to include dizziness and shakiness, is remanded.

Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder (MDD) and anxiety disorder, is remanded.

 

FINDINGS OF FACT

1. The evidence does not indicate a current diagnosis associated with the claimed vein problem, blood poisoning, or feet blisters during the appeal period.  

2. The Veteran has additional disability of ongoing pain, ongoing stiffness, and loss of motion and strength resulting from the VA right-wrist surgeries; however, the additional disability was not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault by VA, nor was the additional disability the result of an event not reasonably foreseeable.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for vein problems have not been met.  38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for entitlement to service connection for blood poisoning have not been met.  38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for entitlement to service connection for feet blisters have not been met.  38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for residuals of surgery to remove giant cell tumor of right wrist have not been met.  38 U.S.C. §§ 1151, 5107; 38 C.F.R. §§ 3.102, 3.361.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had qualifying service from June 1975 to October 1977.

The Veteran’s mental health diagnoses of MDD and anxiety disorder are construed as a single claim for entitlement to service connection for an acquired psychiatric disorder.  Clemons v. Shinseki, 23 Vet. App. 1 (2009).

The RO previously found that the Veteran did not timely appeal a September 2010 rating decision denyig, in pertinent part, service connection for giant cell bone tumor of the right radius.  However, the September 2010 rating decision did not become final because the Veteran submitted timely, informal notice of disagreements (NODs) in September 2010 and November 2010.  In those statements, the Veteran indicated that he desired reconsideration of the denial of entitlement to service connection for blood poisoning and the denial of entitlement to service connection for feet blisters, which are inextricably intertwined with the issue of entitlement to service connection for giant cell bone tumor of the right radius (in this case, the Veteran is contending that blood poisoning from foot blisters during service caused vein problems leading to the right wrist tumor).  Based on a liberal reading, these statements are consistent with an NOD.  See 38 C.F.R. §§ 20.200, 20.201, 20.300, 20.302 (in effect prior to March 24, 2015).  Accordingly, the issue of entitlement to service connection for giant cell bone tumor of the right radius is an original claim.  New and material evidence is not needed to readjudicate the issue notwithstanding the RO’s treatment of the issue to the contrary.  

Service Connection

Direct service connection generally requires evidence showing: (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.  Shedden v. Principi, 381 F.3d 1163, 1167
300, 20.302 (in effect prior to March 24, 2015).  Accordingly, the issue of entitlement to service connection for giant cell bone tumor of the right radius is an original claim.  New and material evidence is not needed to readjudicate the issue notwithstanding the RO’s treatment of the issue to the contrary.  

Service Connection

Direct service connection generally requires evidence showing: (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.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability; in the absence of proof of a present disability, there can be no valid claim.  Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992).      

1. Vein Problems

2. Blood Poisoning

3. Feet Blisters

As issues 1-3 are interrelated, the Board will address them together.  

Specifically, the Veteran essentially contends that blood poisoning from foot blisters during service caused vein problems (leading to a right wrist tumor).  He maintains that this ultimately arose from exposure to aviation fuel; and/or blue dye from pants going into white socks during washing and then blue dye entering his blood stream through feet blisters causing cellulitis, a severe change in acid levels in the blood, and damage to all organs.

The Board concludes that the Veteran does not have a current diagnosis associated with vein problems, blood poisoning, or foot blisters, and has not had one at any time during the pendency of the claim or recent to the filing of the claim.  Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007).  

A July 1975 service treatment record (STR) documented feet blisters, which were treated conservatively with hot soaks and light duty for two days.  The October 1977 separation examination documented no pertinent or ongoing abnormalities.  

During an August 2010 VA feet examination, the Veteran reported no contemporaneous symptoms and stated that his shoe inserts were highly effective.  The August 2010 examiner found no symptoms or functional limitations of the feet (no painful motion, no edema, no weakness, no instability, no tenderness, no limitation of standing or walking, no abnormal weight bearing, no flat foot, no calluses, no onychomycosis, no interdigital maceration, no hammertoes, no arch abnormalities).  Ultimately, the examiner found no current diagnosis and no residuals of the in-service feet blisters.  

The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).  The Veteran appears to indicate that he did not have blisters at present due to wearing inserts.  Generally, if appellant’s condition is subject to active and inactive stages (skin conditions generally), an examination should be conducted during the active stage.  Ardison v. Brown, 6 Vet. App. 405, 408 (1994).  However, based on an overall reading of the opinion, it is clear the VA examiner found no current or past residuals of feet blisters that might be associated with service.  See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012) (A VA examination report “must be read as a whole” to determine the examiner’s rationale.).  Hence, remand for a new examination is not needed.  

A VA examination has not been conducted to address the vein or blood poisoning claims.  However, a VA examination is not warranted based only on the Veteran’s own conclusory, generalized statements, where there is no other supporting evidence in the record.  Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010); Euzebio v. Wilkie, 31 Vet. App. 394 (2019); cf Colantonio v. Shinseki, 606 F.3d 1378, 1381-82 (Fed. Cir. 2010).  To this end
 Hence, remand for a new examination is not needed.  

A VA examination has not been conducted to address the vein or blood poisoning claims.  However, a VA examination is not warranted based only on the Veteran’s own conclusory, generalized statements, where there is no other supporting evidence in the record.  Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010); Euzebio v. Wilkie, 31 Vet. App. 394 (2019); cf Colantonio v. Shinseki, 606 F.3d 1378, 1381-82 (Fed. Cir. 2010).  To this end, while the Veteran believes he has a current diagnosis involving vein problems, he is not competent to provide a diagnosis in this case.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007).  

Absent evidence of a current diagnosis during the appeal period, the claims must be denied.  Brammer, 3 Vet. App. 223; Rabideau, 2 Vet. App. 141.

38 U.S.C. § 1151

A veteran who suffers disability resulting from hospital care or medical or surgical treatment provided by a VA employee or in a VA facility is entitled to compensation for the additional disability “in the same manner as if such additional disability... were service-connected” if the additional disability was not the result of willful misconduct and was proximately caused by “carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of [VA] in furnishing” that treatment or “an event not reasonably foreseeable.”  38 U.S.C. § 1151(a)(1)(A), (B); 38 C.F.R. § 3.361(a)-(d); Viegas v. Shinseki, 705 F.3d 1374, 1377-78 (Fed. Cir. 2013).  The purpose of the statute is to award benefits to those veterans who were disabled because of VA treatment or vocational rehabilitation.  38 U.S.C. § 1151(a).

First, there must be evidence of additional disability, as shown by comparing the veteran’s condition before and after the VA medical care in question.  38 C.F.R. § 3.361(b).  To determine whether a veteran has an additional disability, VA compares the veteran’s condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy (CWT) program upon which the claim is based to the veteran’s condition after such care, treatment, examination, services, or program has stopped.  VA considers each body part or system separately.  The additional disability must not be the result of the veteran’s willful misconduct.  38 U.S.C. § 1151(a); 38 C.F.R. § 3.301(c)(3).  

Second, the additional disability must be caused by hospital care, medical or surgical treatment, examination, training and rehabilitation services, or CWT program furnished the veteran by VA.  38 C.F.R. § 3.361(c).  Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability does not establish cause.  38 C.F.R. § 3.361(c)(1).  For additional disability to be compensable under 38 U.S.C. § 1151, the additional disability must have been caused by, and not merely coincidental to, hospital care, medical or surgical treatment, or medical examination furnished by a VA employee or in a VA facility.  38 C.F.R. § 3.361(c)(1); Loving v. Nicholson, 19 Vet. App. 96, 99-100 (2005); Sweitzer v. Brown, 5 Vet. App. 503, 505 (1993).  That is, the additional disability must have been the result of injury that was part of the natural sequence of cause and effect flowing directly from the actual provision of “hospital care, medical or surgical treatment, or examination” furnished by VA and such additional disability must be directly caused by that VA activity.  Loving, 19 Vet. App. at 101.

Third, the proximate cause of the disability (as opposed to a remote contributing cause) must be: (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (2) an event
503, 505 (1993).  That is, the additional disability must have been the result of injury that was part of the natural sequence of cause and effect flowing directly from the actual provision of “hospital care, medical or surgical treatment, or examination” furnished by VA and such additional disability must be directly caused by that VA activity.  Loving, 19 Vet. App. at 101.

Third, the proximate cause of the disability (as opposed to a remote contributing cause) must be: (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (2) an event that was not reasonably foreseeable.  38 U.S.C. § 1151(a)(1); 38 C.F.R. § 3.361(d).  

Thus, 38 U.S.C. § 1151 contains two causation elements – an additional disability must not only be “caused by” the hospital care or medical treatment received from VA, but also must be “proximate[ly] cause[d]” by the VA’s “fault” or an unforeseen “event.”  38 U.S.C. § 1151(a)(1).

4. Residuals of Surgery to Remove Giant Cell Tumor of Right Wrist 

The Veteran contends that his right wrist has additional disability that was proximately due to the fault of VA surgeons or an unforeseen event.  Specifically, the Veteran asserts that he had wrist motion after the first surgery (not performed by VA), but after the second and third surgeries (performed by VA) his wrist was damaged such that it had to be fused and resulted in permanent loss of motion.  See March 2018 Brief.  

January 2011 and September 2011 Canton VAMC records document residuals of ongoing stiffness, less finger motion and grip strength than desired, and ongoing pain that is aching and sharp.  Additionally, the May 2011 VA examiner and June 2019 VA independent medical examiner explained that there were complications during and after the second surgery, which led to repairs during the second surgery and then ultimately a third surgery.  As such, the Board finds that the Veteran has additional disability in the form of ongoing pain, ongoing stiffness, and loss of motion and strength resulting from the VA surgeries.  Thus, the additional disability element of the claim has been met.  38 U.S.C. § 1151 (a)(1); 38 C.F.R. § 3.361 (b)-(d).

Regarding fault, the Veteran does not have the medical background necessary to competently render an opinion regarding whether any additional disability was proximately due to the fault of VA surgeons or an unforeseen event.  Jandreau, 492 F.3d 1372; Layno, 6 Vet. App. 465; September 2014 VA Form 9; February 2017 Brief; March 2018 Brief; August 2019 Brief.  Accordingly, the Board turns to the competent opinions from the May 2011 VA examiner and June 2019 VA independent medical examiner. 

A May 2011 VA examiner reviewed the two surgeries to remove a giant cell tumor of the right radius bone (first in 2008 and again in 2009 for recurrence) and the arthrodesis of the right wrist (in September 2010); the examiner noted that the third surgery was required to remove failed hardware and fuse the wrist.  During the second surgery, there was injury to radial artery and three extensor tendons; however, the examiner stated that these injuries were noticed and repaired during the surgery without any complications and that these injuries were compilations of the surgery discussed in the consent the Veteran signed.  The examiner noted that the tumor was large and was displacing the radial artery and the adjacent tendons, as described in the operation report; the examiner also stated that scar tissue was noted on the tendons from the previous surgery (not performed by VA).  The examiner explained that the complications were unfortunate, but that they were fixed promptly during the surgery.  As far as the hardware failure, the examiner noted that there was still mobility in the joint, causing the hardware to bend and break.  After review of all evidence, the examiner opined that the Veteran received proper care from the VA and that there was no carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA.

A June 2019 VA independent medical opinion similarly concluded that it is less likely than not that the residuals from the second and third wrist surgeries (those performed by VA) were the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part
 unfortunate, but that they were fixed promptly during the surgery.  As far as the hardware failure, the examiner noted that there was still mobility in the joint, causing the hardware to bend and break.  After review of all evidence, the examiner opined that the Veteran received proper care from the VA and that there was no carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA.

A June 2019 VA independent medical opinion similarly concluded that it is less likely than not that the residuals from the second and third wrist surgeries (those performed by VA) were the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA.  The examiner explained that these complications were identified in the literature and that the Veteran was made aware of them before the surgery when he signed the consent form.  The examiner further opined that it is less likely than not that the Veteran’s residuals from the second and third wrist surgeries were unforeseeable because the VA practitioners exercised the degree of care that is expected of a reasonable health care provider.  

These examiners’ opinions are persuasive, because they were based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).  The examiners reviewed the file, including the surgery reports in question.  

The record contains a June 2009 informed consent form, signed by the Veteran with a witness, that listed the procedure, listed what would happen during the procedure, noted that anesthesia would be used, discussed the benefits and risks of the procedure and the anesthesia, and confirmed that the Veteran requested performance of the procedure while having decision-making capacity.  38 C.F.R. § 17.32 (d).  There is no indication that the Veteran did not give consent freely or that he was otherwise coerced; further, there is no indication that the procedure was novel or unorthodox.  38 C.F.R. § 17.32 (c).  Further, the May 2011 and June 2019 examiners noted that the complications arising from the VA surgeries were discussed in the consent form the Veteran signed and there is no indication from the examiners that the procedures were not followed.  

Considering this evidence, the Board finds that VA’s consent procedures were followed appropriately and that the additional disability was not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault by VA.  38 C.F.R. § 17.32.  Thus, the fault element of the claim has not been met.  38 U.S.C. § 1151 (a)(1)(A); 38 C.F.R. § 3.361 (d)(1).

Regarding foreseeability, the examiners noted that the Veteran’s complications were listed among the possible risks of treatment in the consent form and literature.  Additionally, the June 2019 examiner opined that the residuals from the VA surgeries were not unforeseeable because the VA practitioners exercised the degree of care that is expected of a reasonable health care provider (as outlined in the pre-operative, operative, and post-operative reports).  Section 3.361 clearly adopts an objective standard based on the “reasonable health care provider.”  This means that the actual foreseeability (or “possible foreseeability”) of an event by a treating physician, an expert, or any other health care provider, is not dispositive.  The standard is what a “reasonable health care provider” would have considered to be an ordinary risk of treatment that would be disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32, which requires the primary health care provider to explain the reasonably foreseeable risks associated with the surgery or treatment being provided.  Otherwise stated, merely because a treating physician, expert, or other health care provider actually foresaw certain risks does not mean that a reasonable health care provider with primary care for the patient would have disclosed these risks.  Schertz v. Shinseki, 26 Vet. App. 362 (2013).  Here, however, the examiners did not invoke a presumption of regularity; rather, they explained what a reasonable health care provider would have considered to be an ordinary risk of treatment that would be disclosed in connection with the informed consent procedures.  Considering this evidence, the Board finds that the additional disability was not the result of an event not reasonably foreseeable.  Thus, the foreseeability element of the claim has not been met.  38 U.S.C. § 1151 (a)(1)(B); 38 C.F.R. § 3.361 (d)(2).

In sum, although the Veteran experienced
.  Schertz v. Shinseki, 26 Vet. App. 362 (2013).  Here, however, the examiners did not invoke a presumption of regularity; rather, they explained what a reasonable health care provider would have considered to be an ordinary risk of treatment that would be disclosed in connection with the informed consent procedures.  Considering this evidence, the Board finds that the additional disability was not the result of an event not reasonably foreseeable.  Thus, the foreseeability element of the claim has not been met.  38 U.S.C. § 1151 (a)(1)(B); 38 C.F.R. § 3.361 (d)(2).

In sum, although the Veteran experienced additional disability as a result of the VA surgeries, neither the fault nor foreseeability elements of the claim that would allow for compensation under 38 U.S.C. § 1151 has been met.  Accordingly, the evidence currently associated with the claims file weighs against finding that VA medical services were the proximate cause of additional disability.  The benefit-of-the-doubt rule is not applicable because the preponderance of the evidence is against the Veteran’s claim; thus, compensation under 38 U.S.C. § 1151 is not warranted and the claim must be denied.  38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.

	REASONS FOR REMAND

1. Giant Cell Bone Tumor of the Right Radius

2. Tremors

	The Veteran contends that a right wrist tumor resulted from blood poisoning from foot blisters during service, which caused vein problems that led to the right wrist tumor.  The Veteran further contends that the right wrist tumor and tremors resulted from exposure to aviation fuel in service and/or blue dye from pants going into white socks during washing and then blue dye entering his blood stream through feet blisters causing cellulitis, a severe change in acid levels in the blood, and damage to all organs.  See February 2017 Brief; March 2018 Brief; August 2019 Brief.  

The evidence establishes exposure to aviation fuel during service as this is consistent with the Veteran’s duties as an aviation boatswain mate.  Further, it is generally recognized and understood that exposure to jet fuel may be toxic and may result in long-term, health effects.  Jandreau, 492 F.3d 1372; Layno, 6 Vet. App. 465.  

The Board cannot make a fully-informed decision on the issue because no VA examiner has opined whether the condition may have resulted from his in-service exposure.

4. Acquired Psychiatric Disorder

This issue is remanded for a new VA examination to address whether a psychiatric preexisted service and, if so, whether it was aggravated therein.  

The March 1975 entrance examination did not note mental health abnormalities.  However, an August 2010 VA psychiatric examiner opined that, in pertinent part, the Veteran’s psychiatric diagnoses were most likely the result of either: (a) a severely-disabling right-wrist condition with residuals (including consequent inability to work, no income, the prospect of another wrist operation, the prospect of being evicted in the near future); and/or (b) other nonservice-related factors, including his early childhood abuse, resentment for leaving the service to take care of his parents, and two failed marriages.  Also, a June 2009 neuropsychological evaluation conducted for the Social Security Administration indicated depressive symptoms as a teenager.  

Because the examiner attributed the Veteran’s diagnoses, in part, to early childhood abuse, the Board must remand for an addendum opinion that discusses whether a psychiatric condition preexisted service and, and, if so, whether it was aggravated beyond its natural progression by service.  38 U.S.C. § 1111; Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

The matters are REMANDED for the following action:

1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the claimed giant cell bone tumor of the right wrist and tremors.

The examiner is asked to address whether a current diagnosis is at least as likely as not related to an in-service injury, event, or disease.  For purposes of answering this question, the examiner should assume as true that the Veteran was exposed to aviation fuel during service.  The examiner should address whether that exposure caused or contributed to the onset of the right wrist condition or tremors.  

2. Obtain an addendum opinion regarding the Veteran’s psychiatric disorder.  The examiner should address each of the following:

(a.) Did any current psychiatric condition preexist the Veteran’s active service?  The examiner is asked to consider a June 2009 examination indicating depressive symptoms
 etiology of the claimed giant cell bone tumor of the right wrist and tremors.

The examiner is asked to address whether a current diagnosis is at least as likely as not related to an in-service injury, event, or disease.  For purposes of answering this question, the examiner should assume as true that the Veteran was exposed to aviation fuel during service.  The examiner should address whether that exposure caused or contributed to the onset of the right wrist condition or tremors.  

2. Obtain an addendum opinion regarding the Veteran’s psychiatric disorder.  The examiner should address each of the following:

(a.) Did any current psychiatric condition preexist the Veteran’s active service?  The examiner is asked to consider a June 2009 examination indicating depressive symptoms as a teenager, plus the prior VA examiner’s opinion from August 2010 indicating that a current psychiatric disorder arose, at least in part, from childhood trauma.  

(b.) If preexisting his service, did the condition worsen (i.e., increase in severity) during service?  If yes, was that worsening due to the natural progress of the disease? 

How certain are you in your answers to questions (b) and (c)?  Would any equally qualified medical professional with the same information reasonably be able to reach a different conclusion?

(c.) If you determined in questions (b) and (c) that a condition preexisted service, is it at least as likely as not (i.e., at least equally probable) that the current diagnosis represents the present manifestation of that same condition?  

(Continued on the next page)

 

(d.) If not preexisting service, is it at least as likely as not (i.e., at least equally probable) that any current diagnosis had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service?  If you determined in questions (b) and (c) that a condition preexisted service, this should include consideration of whether the current condition represents the present manifestation of that same condition.

 

C. BOSELY

Acting Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	H. Daus, 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.