GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Summary

The Veteran, an Air Force Veteran who served from December 9, 2003, to December 8, 2007, including a tour in Kuwait, appeals the denial of service connection for gastroesophageal reflux disease (GERD), claimed as secondary to his service-connected posttraumatic stress disorder (PTSD). The Board reviewed evidence of record up to the February 8, 2021, rating decision, including a VA C&P examination and a private medical opinion from the Veteran's treating psychologist, Dr. J.A.G. The Veteran's psychologist opined that there was a periodic connection between his PTSD and stomach distress, which the Board interpreted as at least as likely as not caused by PTSD, assigning moderate probative weight. Conversely, the VA examiner concluded that GERD is not medically linked to PTSD, citing medical literature, and found the Veteran's testimony credible but not indicative of causation. The Board noted that while the VA examiner's negative opinion might typically outweigh the positive one, the agency of original jurisdiction committed pre-decisional error by failing to fully develop the claim for secondary aggravation and for secondary connection with obesity as an intermediate step. Given the conflicting medical opinions and the duty to assist errors, the Board found the evidence at least evenly balanced, applying the benefit-of-the-doubt rule in the Veteran's favor. Consequently, service connection for GERD secondary to PTSD was granted.

Rationale

Conflicting medical opinions from private psychologist and VA examiner.; Board found evidence evenly balanced.; Applied benefit-of-the-doubt rule.; AOJ committed pre-decisional error in development of secondary claims.

Full Decision Text

Citation Nr: A26030400
Decision Date: 04/02/26	Archive Date: 04/02/26

DOCKET NO. 210308-146236
DATE: April 2, 2026

ORDER

Entitlement to service connection for gastroesophageal reflux disease (GERD) (specifically claimed as secondary to posttraumatic stress disorder [PTSD]) is granted.

FINDING OF FACT

Resolving all reasonable doubt in the Veteran's favor, the Veteran has a current and valid diagnosis of gastroesophageal reflux disease (GERD), and it is at least as likely as not either secondary to service-connected PTSD, either with or without obesity as an intermediate step.

CONCLUSION OF LAW

The criteria for entitlement to service connection for gastroesophageal reflux disease (GERD) (specifically claimed as secondary to posttraumatic stress disorder [PTSD]) have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Air Force from December 9, 2003 to December 8, 2007.  This honorable service includes at least one verified tour of duty at Camp Arifjan, Kuwait, from April 17, 2006 to November 15, 2006.  See DD-214 (rec'd Nov. 10, 2017), at Blocks 11-14; DPRIS Response (rec'd Jan. 6, 2018), at Page 5.  This claim on appeal comes before the Board of Veterans' Appeals (Board) on appeal of a February 8, 2021 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

In the March 8, 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on August 2, 2024.  A transcript of the hearing was produced and associated with the claims file for Board review.

Therefore, the Board may only consider the evidence of record at the time of the February 8, 2021 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran at the hearing (as conducted on August 2, 2024) or within 90 days following the hearing.  38 C.F.R. § 20.302(a).  If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision.  38 C.F.R. §§ 20.300, 20.302(a), 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence.  38 C.F.R. § 3.2501.  If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a Supplemental Claim are included with this decision. 

1. Entitlement to service connection for gastroesophageal reflux disease (GERD) (specifically claimed as secondary to posttraumatic stress disorder [PTSD]) is granted.

A claimant may "limit a claim or appeal to the issue of entitlement to a particular disability rating which is less than the maximum disability rating allowed by law" via "clearly expressed intent to limit the appeal to entitlement to a specific disability rating for the service-connected condition."  See AB v. Brown, 6 Vet. App. 35, 39 (1993) (citing Hamilton v. Brown, 4 Vet. App. 528, 544 (1993)).  The Veteran limited his argument to his GERD being secondary to service-connected PTSD, see generally VA Form 21-526EZ (Nov. 9, 2020); Hearing Tr. (Aug. 2, 2024).  The Board will accordingly not interpret any pre-decisional error in violation of any duty to assist in not developing the claim for service connection as direct, and instead by only developing the claim as secondary.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal
 Brown, 4 Vet. App. 528, 544 (1993)).  The Veteran limited his argument to his GERD being secondary to service-connected PTSD, see generally VA Form 21-526EZ (Nov. 9, 2020); Hearing Tr. (Aug. 2, 2024).  The Board will accordingly not interpret any pre-decisional error in violation of any duty to assist in not developing the claim for service connection as direct, and instead by only developing the claim as secondary.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument).  Ultimately, service connection for GERD on a direct basis and service connection for GERD as secondarily caused by PTSD are each full grants of the benefit sought on appeal, so the Veteran is ultimately not prejudiced.

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service.  38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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); see also Caluza v. Brown, 7 Vet. App. 498 (1995).  Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury.  Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)].

Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases such as psychosis to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service.  38 U.S.C. §§ 1101, 1110, 1112; 38 C.F.R. §§ 3.307, 3.309.

Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service.  See 38 C.F.R. § 3.303(b).  However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint.  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection also may be established on a secondary basis for: (1) a disability that is proximately due to or the result of a service-connected disease or injury; or (2) any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury.  38 C.F.R. §§ 3.310(a)-(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (explaining 38 C.F.R. § 3.310(b)). 

VA's Office of General Counsel (OGC) issued a precedential opinion finding that obesity may be an "intermediate step" between a service-connected disability and a current disability that may be connected on a secondary basis.  In order to meet these criteria, the Veteran must demonstrate that
 a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury.  38 C.F.R. §§ 3.310(a)-(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (explaining 38 C.F.R. § 3.310(b)). 

VA's Office of General Counsel (OGC) issued a precedential opinion finding that obesity may be an "intermediate step" between a service-connected disability and a current disability that may be connected on a secondary basis.  In order to meet these criteria, the Veteran must demonstrate that a previously service-connected disability caused him to become obese; obesity was a substantial factor in causing secondary disability; and the secondary disability would only have occurred but for the obesity.  VAOPGCPREC 1-2017 (January 6, 2017).  The Veteran was diagnosed with clinical obesity no later than March 2018, see VA Medical Records (Mar. 2, 2018, rec'd Feb. 6, 2021), at Page 127 (body-mass index of 30), so resolving all reasonable doubt in the Veteran's favor, the Board will assume that obesity manifested for at least one day during the appellate period, even if it may have resolved via weight loss during the appellate period.  See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). 

The veteran can provide competent reports of factual matters of which they have first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy.  See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005).  Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).  Similarly, laypersons are competent to diagnose and provide nexus opinions to some extent, notably where the diagnosis or opinion is not of a complex nature.  Id.  See also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).  To the extent that any such evidence may be relevant to the Veteran's claims, the Veteran's military occupational specialty (MOS) was vehicle operations journeyman (2T151), see DD-214, supra at Block No. 11, and the Board has no reason to impugn the Veteran's credibility in detailing circumstances related to his performance of his duties pursuant to his MOS.  See 38 U.S.C. § 1154(a).

When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant.  38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

There is no serious dispute that the Veteran has a valid diagnosis of GERD.  See C&P Exam ( Nov. 30, 2020 ), at Pages 1-2 (detailing diagnosis no later than 2018); Rating Decision (Feb. 8, 2021), at Page 3 of 3 ("Favorable Findings identified in this decision:").  Meanwhile, the Veteran's PTSD is also service connected, rated 50 percent effective November 9, 2017.  See Rating Decision (Codesheet) (Feb. 8, 2021).

The only remaining question is whether there is a nexus between these two, i.e., whether the Veteran's current GERD is secondary to his service-connected PTSD, either with or without obesity as an intermediate step.  The Board notes that the record contains two medical opinions which must be considered and weighed.  See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)).  See also Guerrieri v.
 50 percent effective November 9, 2017.  See Rating Decision (Codesheet) (Feb. 8, 2021).

The only remaining question is whether there is a nexus between these two, i.e., whether the Veteran's current GERD is secondary to his service-connected PTSD, either with or without obesity as an intermediate step.  The Board notes that the record contains two medical opinions which must be considered and weighed.  See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)).  See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (stating that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board).  When faced with conflicting medical opinions, the Board may favor one medical opinion over the other.  See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995).  The Board will consider the opinions below. 

In sum and substance, the Veteran's clinical psychologist, Dr. J.A.G., Ph.D., offered the following conclusion:

I have been treating [the Veteran] for some time now due to PTSD and anxiety.  Over the course of treatment, he has often cited extreme stomach distress that has bordered on incapacitation, and often seems to be associated with PTSD/stress flare-ups.  It is my clinical impression that there is a periodic connection between his psychological disorder and his acute stomach distress.

See Medical Treatment Record (Jan. 18, 2021, rec'd Jan. 27, 2021).  The Board will accept the opinion as if Dr. J.A.G. meant to state that GERD is at least as likely as not (evidence at least evenly balanced) caused by PTSD.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.").  The Board assigns the opinion moderate probative weight.

On the other hand, a VA examiner determined the opposite:

GERD is a result of excessive movement of gastric juice from the stomach into the esophagus due to reduced lower esophageal sphincter tone and/or a disruption of the gastroesophageal junction often associated with a hiatal hernia.  The veteran's statement is considered credible and carefully reviewed.  While the Veteran's testimony of the temporal relationship between his father's passing and GERD diagnosis, and his psychologist's impression of "periodic connection between psychological disorder and his acute stomach distress" are compelling, they do no[t] imply causation.  The fact remains that the medical literature does not support that PTSD causes GERD.

See C&P Exam (Opinion) (Feb. 5, 2021) (internal quotation in the original).  

The Veteran offered testimony that while he believes that GERD is secondary to PTSD because it manifested later, it initially manifested shortly after his father's death, and his GERD is currently exacerbated by flashbacks to service, familial stressors such as his father's death and his daughter's relocation from his home, the novel coronavirus pandemic (COVID-19).  See generally Hearing Tr. (Aug. 2, 2024), at Pages 8-13, 17.  The Board assigns moderate probative weight to the negative conclusion, because it appears to fully consider all relevant positive evidence consistent with the Veteran's arguments, even if the VA examiner may have determined that GERD is caused by family matters or other non-service-connected circumstances of civilian life.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).

Even though the Board might otherwise assign more probative weight to the negative opinion than the positive opinion, the Board could charge the AOJ with pre-decisional error, in violation of the duty to assist in developing the Veteran's claim, by the following two ways: both by (a) failing to obtain an opinion about whether the Veteran's PTSD at least as likely as not secondarily aggravates otherwise-non-service-connectable GERD, and
 is caused by family matters or other non-service-connected circumstances of civilian life.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).

Even though the Board might otherwise assign more probative weight to the negative opinion than the positive opinion, the Board could charge the AOJ with pre-decisional error, in violation of the duty to assist in developing the Veteran's claim, by the following two ways: both by (a) failing to obtain an opinion about whether the Veteran's PTSD at least as likely as not secondarily aggravates otherwise-non-service-connectable GERD, and by (b) failing to obtain an opinion that addresses the relevance or lack thereof of obesity, in the event that it may be an intermediate step between the Veteran's PTSD and GERD.  The Veteran specifically argued that GERD should be secondary to PTSD, and the Board must adjudicate all theories of entitlement reasonably inferable from the record.  See Robinson v. Peake, 21 Vet. App. 545, 552 (2008); cf. Scott v. McDonald, supra.  By developing this claim for service connection as secondary to PTSD, the AOJ committed pre-decisional error by not developing claims for secondary aggravation, or as secondary with obesity as an intermediate step.  See Dickens, supra. 

The evidence of record is at least evenly balanced, so the benefit-of-the-doubt rule applies.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).  Service connection for GERD is ultimately warranted and accordingly must be hereby GRANTED.  This is a full grant of the benefit sought on appeal; therefore, there is no remaining reasonable doubt to resolve.  

 

J.P. Norman

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Engle, Michael B.

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.