RESIDUALS OF ENCEPHALITIS

Summary

The veteran, who served from October 2003 to October 2007, appeals the denial of service connection for a Traumatic Brain Injury (TBI). The Board reviewed the evidence, including service treatment records from a May 2005 motor vehicle accident where the veteran reported minor injuries and slight headache pain, but no significant trauma. Post-service records showed a negative TBI screening in January 2008, though the veteran later reported a TBI during a 2018 evaluation, which the clinician determined resolved within 24 hours. A subsequent VA examination in August 2018 concluded the veteran's current symptoms, such as vertigo, dizziness, light sensitivity, and headaches, were more likely due to PTSD and functional impairment, not a residual TBI. The Board found the evidence persuasively weighed against a current TBI diagnosis, noting the lack of temporal association between the in-service injury and current symptoms, and the absence of a current diagnosis. The Board gave more weight to the medical evidence that did not support a TBI diagnosis over the veteran's lay testimony. Service connection for TBI was denied.

Rationale

No current diagnosis of TBI; In-service TBI symptoms resolved within 24 hours; Current symptoms attributed to PTSD and functional impairment

Full Decision Text

Citation Nr: A26040055
Decision Date: 04/29/26	Archive Date: 04/29/26

DOCKET NO. 200610-91992
DATE: April 29, 2026

ORDER

Entitlement to service connection for a traumatic brain injury (TBI) is denied.

FINDING OF FACT

The evidence of record persuasively weighs against finding that the Veteran has a current disability of a TBI at any time during or approximate to the pendency of the claim.

CONCLUSION OF LAW

The criteria for entitlement to service connection for TBI have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from October 2003 to October 2007. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2020 Statement of the Case issued by the Department of Veterans Affairs (VA) Regional Office (RO). 

In the June 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held in June 2024. Therefore, the Board may only consider the evidence of record at the time of the April 2020 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing 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.

The Veteran contends that he is entitled to service connection for a TBI. See June 2020 Notice of Disagreement. 

Generally, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

In the absence of a current diagnosed disability, service connection cannot be granted for such disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or at any time during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007).

When there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt shall be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When the evidence persuasively favors one side or the other, the benefit-of-the-doubt rule does not apply. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001).

The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.

The Board concludes that the Veteran does not have a current diagnosis of a TBI 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).

The Veteran's service treatment records detail a May 2005 motor vehicle accident, during which the Veteran was asleep in the backseat of a vehicle when he was jolted awake as the vehicle rolled over. The Veteran reported no significant injuries aside from a sore lip and was spitting blood. He did mention experiencing slight headache pain to the back of his head,
 have a current diagnosis of a TBI 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).

The Veteran's service treatment records detail a May 2005 motor vehicle accident, during which the Veteran was asleep in the backseat of a vehicle when he was jolted awake as the vehicle rolled over. The Veteran reported no significant injuries aside from a sore lip and was spitting blood. He did mention experiencing slight headache pain to the back of his head, which was tender to the touch; however, there were no deformities or acute distress. See May 2005 Medical Record Note. 

Post-service treatment records indicate that in January 2008, the Veteran underwent a TBI screening in which he reported feeling dazed, confused, or seeing stars after a vehicle accident during his deployment. However, he denied any problems that began or worsened afterward. The examiner concluded that screening was negative for TBI. In May 2018, during a primary care visit, the Veteran requested to see the TBI clinic. In July 2018, the Veteran was provided with a comprehensive TBI evaluation. The clinician determined that, based on the history of the injury and the course of clinical symptoms, he did sustain a TBI during his deployment, but the symptoms were resolved in 24 hours. The onset of the current symptoms on the neurobehavioral inventory is not temporally associated with the injury. It was also noted that the Veteran has concomitant conditions, including PTSD, depression, and chronic pain, which most likely account for current symptomatology. See July 2018 TBI Neurobehavioral Inventory Consult Results.

In August 2018, the Veteran underwent a VA initial evaluation of residuals of TBI. The VA examiner evaluated the Veteran and concluded that the Veteran's TBI was likely resolved, and that his current complaints detailed in section II are likely due to another etiology, not TBI. He also noted that the Veteran had a TBI evaluation in July 2018, where the examiner indicated the Veteran experienced a TBI with symptom resolution within 24 hours, and his current presentation was most consistent with behavioral health. The VA examiner stated that the Veteran does not appear to have a cognitive disorder related to a TBI. His overall level of reported TBI was mild, and a mild TBI carries only a very low risk of ongoing cognitive sequelae. The examiner further indicated that the Veteran's symptoms did not show the improvement with time that would normally be expected with a TBI-related cognitive deficit. It was determined that the cognitive symptoms observed were more likely the result of functional impairment associated with posttraumatic stress disorder (PTSD). 

During a June 2024 Board hearing, the Veteran reported experiencing symptoms of vertigo, dizziness, sensitivity to light, and headaches, which he associates with the in-service accident. He mentioned that he was diagnosed with post-concussion syndrome in 2021 but is not currently receiving treatment. Additionally, he noted that his doctors have indicated that his current symptoms are associated with his PTSD. 

After considering the allowable evidence of record, the Board finds that the evidence is persuasively against the claim.

The Board concludes that although the service treatment records reflect that the Veteran experienced an acute TBI due to a motor vehicle accident while in service, the probative medical evidence of record does not support a finding that the Veteran has a current diagnosis of TBI or experienced residuals of a TBI related to the in-service accident at any time during or approximate to the pendency of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. at 319, 321 (2007). Additionally, the Veteran has not reported receiving a diagnosis from a clinician. 

In reaching this conclusion, the Board has considered the Veteran's statements that he believes his symptoms are related to the in-service accident. The Veteran is competent to provide testimony on matters he has personally experienced, including observable symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Nevertheless, he is not competent to provide an opinion as to a diagnosis or as to the nature and etiology of his current symptoms. Thus, his lay opinion does not constitute competent evidence and lacks probative value. Consequently, the Board gives more probative weight to the competent medical evidence failing to provide a diagnosis of TBI. 

The Board acknowledges that VA medical records corroborate a diagnosis of post-concussion syndrome from 2021
 that he believes his symptoms are related to the in-service accident. The Veteran is competent to provide testimony on matters he has personally experienced, including observable symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Nevertheless, he is not competent to provide an opinion as to a diagnosis or as to the nature and etiology of his current symptoms. Thus, his lay opinion does not constitute competent evidence and lacks probative value. Consequently, the Board gives more probative weight to the competent medical evidence failing to provide a diagnosis of TBI. 

The Board acknowledges that VA medical records corroborate a diagnosis of post-concussion syndrome from 2021. However, this diagnosis was associated with a fall experienced in December 2021, and there has been no further treatment since then. Additionally, the records indicate that the Veteran has been service connected for PTSD since August 2013 and for migraine headaches since February 2018.

Accordingly, because a current disability is the cornerstone of service connection, and there is no current diagnosis of TBI, the claim for entitlement to service connection for TBI must be denied. See Brammer, 3 Vet. App. at 225; see also Degmetich v. Brown, 104 F.3d 1328, 1332 (1997).

 

 

A. C. MACKENZIE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Rivera Pagan, Cristina A.

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.