DIABETES MELLITUS

THOMAS H. O'SHAY · 2026 · Case ID: 26004295

DENIED

Summary

The Veteran, who served from November 2001 to May 2002 and March 2003 to August 2003, including service in Southwest Asia, appeals the denial of service connection for hemochromatosis. The Veteran asserts the condition resulted from burn pit exposure during service and was aggravated by service-connected PTSD due to alcohol abuse. The Board noted the Veteran is a Persian Gulf Veteran but that hemochromatosis, a known clinical diagnosis, is not a presumptive condition under the PACT Act or Gulf War regulations. VA examinations in November 2025 and December 2025, along with January 2026 addenda, found the Veteran's hemochromatosis to be a congenital genetic disorder that predated service and was not aggravated by service. Service treatment records were silent for symptoms of iron overload, and post-service records showed the condition was well-controlled. The Board found the VA opinions persuasive, citing the gradual progression of the genetic condition and lack of evidence linking it to in-service exposures or alcohol abuse. A February 2017 VA treatment record offering a favorable opinion was discounted for lack of clinical data and rationale. The Board denied service connection for hemochromatosis, finding the evidence persuasively against the claim.

Rationale

Congenital genetic disorder predating service.; Service treatment records silent for symptoms.; VA opinions found condition not related to service exposures or PTSD.; No evidence of alcohol abuse aggravating the condition.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

16-21 840

Full Decision Text

Citation Nr: 26004295
Decision Date: 04/07/26 Archive Date: 04/07/26

DOCKET NO. 16-21 840
DATE: April 7, 2026

ORDER

Entitlement to service connection for service connection for hemochromatosis is denied.

FINDING OF FACT

Clear and unmistakable evidence shows both that the Veteran's hemochromatosis is a congenital disease that preexisted his military service and there is no competent evidence that it was aggravated by service or by service-connected posttraumatic stress disorder (PTSD).

CONCLUSION OF LAW

The criteria for service connection for hemochromatosis are not met. 38 U.S.C. §§ 1110, 1117, 1119, 1120, 1153, 5107; 38 C.F.R. §§ 3.303, 3.304(b), 3.306, 3.310, 3.317, 4.9.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from November 2001 to May 2002, and from March 2003 to August 2003

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).

In February 2024, the Board issued a decision that in part, denied service connection for hemochromatosis. The Veteran appealed the denial to the Court of Appeals for Veterans Claim (Court). In an October 2024 Order, pursuant to a Joint Motion for Partial Remand (JMPR) filed by the parties, the Court vacated and remanded the Board's denial of entitlement to service connection for hemochromatosis, for compliance with the instructions in the JMPR.

This matter was last before the Board in October 2025, when it was remanded for further development.

Service Connection

The Veteran seeks service connection for hemochromatosis that he asserts is the result of exposures while deployed to Southwest Asia (SWA) during his second period of active service. Specifically, he recounts being in close proximity to fire or burn pits while there and that he was disqualified for retention when he received his diagnosis following his deployment. In addition, the Board sua sponte raised the Veteran's possible exposure to leishmaniasis, malaria, and tuberculosis as a plausible link to his hemochromatosis in its April 2020 remand. The Veteran's representative alternatively argues that the Veteran's hemochromatosis was aggravated by his service-connected PTSD, in that alcohol abuse attributable to it, led to, accelerated, or was an earlier manifestation of the condition.

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, 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 - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Continuity of symptomatology may also provide a basis for a grant of service connection for those diseases defined as "chronic" by VA. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection may also be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability resulting from an undiagnosed illness or
no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Continuity of symptomatology may also provide a basis for a grant of service connection for those diseases defined as "chronic" by VA. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection may also be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness that became manifest to any degree at any time, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.§§ 1117, 1118; 38 C.F.R.§ 3.317; see also Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxins Act of 2022 (PACT Act). For covered veterans, service connection for certain diseases also may be presumed based on exposure to burn pits and other toxins (BPOT) during service. 38 U.S.C. §§ 1119, 1120.

Service connection may be granted on a secondary basis for a disability which is due to, or the result of, a service-connected disorder. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 446 (1995) (en banc). In order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). Secondary service connection may be found in certain instances in which a service-connected disability aggravates another disorder. 38 C.F.R. § 3.310(b).

hemochromatosis

In March 2024 the AOJ issued a VA memorandum which confirmed the Veteran is considered a Persian Gulf Veteran as specified by 38 U.S.C. § 1117. However, because hemochromatosis is a known clinical diagnosis, to the extent the claim could be based on an undiagnosed illness incurred during Persian Gulf service under 38 C.F.R.§ 3.317, it is precluded. See also VAOPGCPREC 8-98. The Veteran's participation in a toxic exposure risk activity (TERA), including exposure to burn pits was also conceded based on his military service in SWA. However, hemochromatosis is not among the certain diseases for which service connection may be presumed based on exposure to BPOT. 38 U.S.C. § 1120(b). Also of record is July 2003 notice of possible exposure to infectious diseases while deployed for Operation Iraqi Freedom which confirms the Veteran's possible exposure to leishmaniasis, malaria, and tuberculosis, but does not list hemochromatosis as a potential outcome.

Although service connection may still be established with proof of direct causation, per Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994), all indications are that the Veteran's hemochromatosis is a congenital abnormality. Specifically, VA examiners have discussed the service and post-service treatment records and found that the Veteran's hemochromatosis is a congenital disorder that clearly and unmistakably preexisted service. See November 2025 VA Medical Opinion Disability Benefits Questionnaire (DBQ) and Addendums dated in December 2025 and January 2026. Congenital conditions, by definition, occur at birth and necessarily pre-exist military service.

Service connection is available for preexisting conditions aggravated during service beyond the course of their natural progression. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. The law provides that Veterans are presumed sound upon entry into service except for conditions noted upon entry or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Only such disorders as are recorded in examination reports are considered as noted. 38 U.S.C. § 1111; 38 C.F.R. §
2026. Congenital conditions, by definition, occur at birth and necessarily pre-exist military service.

In Wagner v. Principi, 370 F.3d 1089, 1096 (2004), the United States Court of Appeals for the Federal Circuit held if a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder but may bring a claim for service-connected aggravation of that disorder. In that case, 38 U.S.C. § 1153 applies and the burden falls on the veteran to establish an increase in disability during service. If the presumption of aggravation attaches, the burden shifts to the government to show by clear and unmistakable evidence that there has been no increase in the severity of the preexisting condition or that any increase was the result of natural progression. Id; see also 38 C.F.R. § 3.306(b). A temporary or intermittent flare-up of a preexisting disease does not constitute aggravation unless the underlying condition, as contrasted to symptoms, is permanently worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993), citing Hunt v. Derwinski, 1 Vet. App. 292 (1991).

In the case of congenital abnormalities, service connection may be established for a disease of congenital origin that first manifests during service or preexisted service but progresses beyond its natural progression during service. Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009). On the other hand, a congenital defect is not considered a disability for which service connection can be granted. 38 C.F.R. §§ 3.303 (c), 4.9; see also Quirin at 390 (holding that the presumption of soundness does not apply to congenital defects); Winn v. Brown, 8 Vet. App. 510, 516 (1996) (holding that a non-disease or non-injury entity such as a congenital defect is "not the type of disease-or injury-related defect to which the presumption of soundness can apply"). However, VA policy provides that if the defect was aggravated such that a superimposed disease or injury occurred during service; service connection may be established for the resultant disability.

Service treatment records are silent for any ongoing complaints or symptoms indicative of hemochromatosis. At his July 2003 Post Deployment Assessment, the Veteran reported his health got worse while in SWA. However, he also denied weakness, joint pain, fatigue, or any other symptoms that might suggest hemochromatosis and reported that his current health was in general "very good." There were no referrals indicated for fatigue, malaise or multi-system complaints. His separation examination, performed on the same day in July 2003, found no interval change since his October 2001 entrance examination. The lack of in-service findings/problems related to hemochromatosis weighs against a finding of worsening (increase) during service and the presumption of aggravation is not established.

This conclusion is further supported by post-service records which show the Veteran continued to serve as a reservist until May 2007 when he was found to have a homozygous gene defect and diagnosed with hemochromatosis four years after his last period of active service. As a result of his diagnosis, he was subsequently disqualified from retention in the Reserve (there is no argument or indication for considering any active or inactive duty training).

Private treatment records show between 2009 and 2014 the Veteran was seen for periodic phlebotomy treatments to manage his ferritin levels due to iron overload from hemochromatosis. In general, his overall health was good, and his symptoms were considered under reasonably good control. A November 2014 entry shows the Veteran reported that he was feeling well with no change in his health and good energy level. See clinical records from Broome Oncology. VA treatment records from 2005 to 2018 show that more often than not the Veteran denied symptoms commonly
of his diagnosis, he was subsequently disqualified from retention in the Reserve (there is no argument or indication for considering any active or inactive duty training).

Private treatment records show between 2009 and 2014 the Veteran was seen for periodic phlebotomy treatments to manage his ferritin levels due to iron overload from hemochromatosis. In general, his overall health was good, and his symptoms were considered under reasonably good control. A November 2014 entry shows the Veteran reported that he was feeling well with no change in his health and good energy level. See clinical records from Broome Oncology. VA treatment records from 2005 to 2018 show that more often than not the Veteran denied symptoms commonly associated with hemochromatosis such as fatigue, arthralgias, weakness, fever, night sweats, or chills. See Syracuse VA Medical Center (VAMC) dated from 2005 to 2018. The most recent entry dated October 2017 shows the Veteran denied fatigue or arthralgias and reported an active lifestyle with work and hobbies such as fishing and snowmobiling. See VA Hematology/Oncology Clinic Note October 4, 2017.

In January 2021 a VA examiner confirmed the hemochromatosis diagnosis finding that it was less likely than not related to the Veteran's service including specifically to his exposures. The examiner described hemochromatosis as a rare genetic condition secondary to a gene mutation related to iron metabolism and that individuals with the condition tend not to present symptoms until adulthood. It was noted that this was consistent with the Veteran presenting symptoms later in his life, after his SW deployment, where they were not present before it. The examiner stated that based on their relevant medical knowledge as well as a relevant medical literature they were not aware of any environmental exposures that cause hemochromatosis that are specific to the Veteran's SWA deployment, including both his presumed BPOT exposures as well as his possible exposures to leishmaniasis, malaria, and tuberculosis.

Additional VA opinions were obtained from another examiner who stated there was no basis for findings of hemochromatosis onset during the Veteran's active service and no evidence to establish that his complaints of fatigue, weakness, and joint pain caused it but instead indicated that it was a congenital disease that existed prior to service and was not aggravated in service. Citing to medical references the examiner explained that hemochromatosis is a condition that causes the body to absorb too much iron from food. Excess iron is stored in the organs, especially the liver, heart and pancreas and too much of it can lead to life-threatening conditions, such as liver disease, heart problems and diabetes. Hemochromatosis is most often caused by a change in a gene which controls the amount of iron the body absorbs from food. The altered gene is passed from parents to children and is by far the most common type of hemochromatosis - hereditary hemochromatosis. Factors that increase the risk of hemochromatosis include having two copies of an altered HFE gene, family history, ethnicity, and gender. There is no medical literature indicating the Veteran's specific in-service exposures would result in any risk factors related to hemochromatosis.

The examiner went on to explain that hemochromatosis is a congenital disease and not a defect. A congenital disease is a hereditary condition that can progress over time, which applies to hereditary hemochromatosis (HFE-related). Hemochromatosis involves progressive iron overload, organ injury, and worsening clinical manifestations; therefore, it meets the definition of a congenital disease. Hemochromatosis is caused by HFE gene mutations present from birth, making preexistence medically undeniable. After careful review of the file, the examiner found no medical records to show the Veteran's complaints, and treatment of hemochromatosis-related symptoms that would establish that his condition was aggravated in service. The examiner also determined that the hemochromatosis was less likely than not (likelihood is less than approximately balanced or nearly equal) caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran.

In a December 2025 addendum, the examiner reiterated their previous opinion the Veteran's hemochromatosis was not related to his in- service TERA exposures. She noted that the Veteran was diagnosed with hemochromatosis in May 2007, several years after completion of active duty and while serving in the reserve. Service treatment records including deployment and separation evaluations are silent for findings consistent with iron overload, such as abnormal liver function, hyperpigmentation, diabetes, cardiomyopathy, or chronic arthropathy. The July 2003 Post-Deployment Health Assessment documents complaints of headaches and breathing issues but does not document fatigue, weakness, or joint pain suggestive of iron overload at that time. The examiner also noted that the Veteran's June 2007 statement reporting fatigue and weakness "for several years" has been considered and while fatigue can be a symptom of iron overload, it is nonspecific and commonly overlaps with numerous conditions. Importantly, hemochromatosis develops gradually over decades, and the onset of symptoms years after service is consistent with the natural progression of a genetic condition, not an acquired service-related disease. Therefore, the Veteran's hemochromatosis is most consistent with genetic inheritance and natural disease progression, rather than any event, exposure, or symptom during active service.

The examiner also noted review of the July 2003 notice of possible infectious exposure during deployment and stated there was no medical evidence or literature supporting infectious disease exposure as a cause, trigger, or accelerator of hereditary hemochromatosis. Environmental or toxic exposures similarly do not alter iron-regulating gene expression responsible for this condition. Therefore, the Veteran's hemochromatosis was less likely than not (likelihood is less than approximately balanced or nearly equal) caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran.

In a January 2026 addendum, the VA examiner noted the Veteran's June 2007 lay statement reports experiencing fatigue and weakness for "several years now" had been reviewed, considered, and accepted as credible. She then continued to reiterate that while fatigue and weakness are recognized symptoms that can occur in hemochromatosis, they are nonspecific symptoms that overlap with numerous medical and non-medical conditions, including sleep disturbance, mood disorders, anemia, endocrine disorders, deconditioning, and other chronic illnesses. More importantly, the Veteran's June 2007 report of fatigue and weakness does not identify a diagnosis of hemochromatosis, nor does it provide evidence of iron overload, abnormal ferritin or transferrin saturation, organ involvement, or other objective findings that would establish onset or progression of hemochromatosis during service. While the Veteran reports symptoms for "several years," this timeframe does not medically establish when iron accumulation reached a pathological threshold, as hereditary hemochromatosis progresses gradually over decades and is often asymptomatic or nonspecific early on.

She also restated that hemochromatosis is a genetic disorder (most commonly hereditary hemochromatosis due to HFE gene mutations) characterized by progressive iron accumulation over time. While symptoms such as fatigue, weakness, and joint pain can occur in hemochromatosis, they are nonspecific and commonly overlap with numerous other medical conditions. The presence of these symptoms alone does not establish onset, causation, or diagnosis of hemochromatosis. As hemochromatosis is a hereditary genetic disorder, the genetic predisposition existed prior to the Veteran's entry into service, even though the condition may not have been clinically apparent or diagnosed until years later. Citing to medical references the examiner explained that most people with hemochromatosis inherit it from their parents - hereditary hemochromatosis, or primary hemochromatosis and that it takes two copies of the altered gene - one from each parent - to develop hemochromatosis. If the parents each have only one copy, they likely won't have the condition or know about the gene. Changes in the HFE gene usually cause hereditary hemochromatosis. The two most common variants are C282Y and H63D. A less common form of the condition, called juvenile hemochromatosis, comes from changes in the HJV or HAMP genes. These changes cause iron to build up much more quickly, so symptoms appear sooner. Juvenile hemochromatosis
from their parents - hereditary hemochromatosis, or primary hemochromatosis and that it takes two copies of the altered gene - one from each parent - to develop hemochromatosis. If the parents each have only one copy, they likely won't have the condition or know about the gene. Changes in the HFE gene usually cause hereditary hemochromatosis. The two most common variants are C282Y and H63D. A less common form of the condition, called juvenile hemochromatosis, comes from changes in the HJV or HAMP genes. These changes cause iron to build up much more quickly, so symptoms appear sooner. Juvenile hemochromatosis typically appears between the ages of 15 and 30.

Based on the evidence in this case service connection for hemochromatosis is denied. As noted above, there is no evidence of objective documentation or pertinent complaints or findings during service and the Veteran specifically denied weakness, joint pain, and fatigue symptoms following his 2003 deployment assessment ultimately describing his health as very good. In addition, post service records show the Veteran's his hemochromatosis was considered under reasonably good control and that his overall health and energy level were both good; he felt well and had an active lifestyle. The Board finds no reason that the Veteran would not have accurately reported symptoms at that time of these evaluations.

Moreover, the VA opinions are both probative and persuasive medical evidence in this case, as they are based upon a review of the claims file and supported by sound medical rationale consistent with the evidence documented in the record. There is no indication that the examiner overlooked relevant medical or other history and the opinion reflects consideration of the Veteran's in-service toxic exposure history, his lay statements regarding onset and course of his condition and current medical resources in support of the conclusion. The examiner explained in great detail why the Veteran's hemochromatosis is not related to his inservice toxic exposures during his deployment. Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). The claims file contains no competent medical evidence refuting it.

So, while the Veteran clearly had hemochromatosis before service, his service treatment records, post-service outpatient records, and VA medical opinions discussed above provide strong evidence against a permanent worsening of the Veteran's preexisting congenital hemochromatosis during his period of active duty in 2002.

The Board has also considered a February 2017 VA treatment record in which a physician's assistant opined that "it would seem more likely than not that [the Veteran's] military service resulted in developing iron overload and other hematological abnormalities requiring treatment," but did not reference any clinical data or other evidence to support the opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (the failure of a physician to provide a basis for his or her opinion affects the weight or credibility of the evidence); Bloom v. West, 12 Vet. App. 1985 (1999) (holding that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion."). Therefore, this opinion is not probative and cannot support a grant of service connection.

The Veteran is also not entitled to service connection for hemochromatosis as secondary to his service-connected PTSD on an aggravation basis. This argument is problematic for two reasons. First, it relies upon the Veteran abusing alcohol. The basis for this is a July 2021 VA treatment record in which he recounted that he used to drink two six packs of beer per week. Yet no relevant details were provided, such as to when or how long he drank so much. All other VA treatment records as well as private treatment records document that he drinks alcohol minimally (descriptors such as rarely, infrequently, never, and occasionally were used). In an August 2016 private treatment record, he denied a history of excessive ethanol use. That the Veteran abused alcohol, in sum, has not been established. Second, the argument indicates alcohol abuse leads to accelerated or earlier manifestation of hemochromatosis. Nothing has been offered as evidence (see introduction) to show the Veteran had accelerated or earlier manifestation, however. No support for alcohol abuse causing it has been offered as evidence either.

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Given these problems with the Veteran's representative's argument, a VA medical opinion to address secondary service connection for hemochromatosis on an aggravation basis is not required.
rarely, infrequently, never, and occasionally were used). In an August 2016 private treatment record, he denied a history of excessive ethanol use. That the Veteran abused alcohol, in sum, has not been established. Second, the argument indicates alcohol abuse leads to accelerated or earlier manifestation of hemochromatosis. Nothing has been offered as evidence (see introduction) to show the Veteran had accelerated or earlier manifestation, however. No support for alcohol abuse causing it has been offered as evidence either.

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Given these problems with the Veteran's representative's argument, a VA medical opinion to address secondary service connection for hemochromatosis on an aggravation basis is not required. There simply is no indication of such a relationship, even with the low threshold required for such an indication to trigger the duty to assist in providing an opinion. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran and his representative may believe one exists, but that is insufficient. See Waters v. Shinseki, 601 F.3d 1274, 1275 (Fed. Cir. 2010) (rejecting that opinions are to be routinely and virtually automatically provided to all veterans in cases involving nexus issues).

Accordingly, the evidence is persuasively against the claim for all theories addressed and there is no reasonable doubt to be resolved. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

Thomas H. O'Shay

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Bryant, Jeana R

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.

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