Citation Nr: 1736586	
Decision Date: 08/31/17    Archive Date: 09/06/17

DOCKET NO.  10-04 054	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in San Diego, California


THE ISSUE

Entitlement to service connection for the cause of the Veteran's death.


REPRESENTATION

Appellant represented by:	The American Legion


ATTORNEY FOR THE BOARD

J. W. Kim, Counsel




INTRODUCTION

The Veteran served on active duty from March 1942 to November 1945.  The Veteran is deceased, and the appellant is his surviving spouse.

This case is before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California.  In March 2016, the Board remanded the case for further development.

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016).  38 U.S.C.A. § 7107(a)(2) (West 2014).

The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ).  VA will notify the appellant if further action is required.


REMAND

Regrettably, the Board finds that another remanded is needed prior to the Board's adjudication of this case.

The Veteran's death certificate states that the causes of death were congestive heart failure and coronary artery disease.  It also states that atrial fibrillation, diabetes mellitus, chronic kidney disease, cerebral vascular accident, colon cancer, gout, gastroesophageal reflux disease, and hypothyroidism were significant conditions contributing to death but not resulting in the underlying cause of death.

At the time of his death, the Veteran was service-connected for burn scars on various areas of his body and adjustment disorder with anxiety and depression.

The appellant asserts that the Veteran's service-connected psychiatric condition aggravated his hypertension and heart disease, and thereby caused or substantially contributed to his death.  See January 2009 letter from appellant.  The appellant also submitted literature suggesting that posttraumatic stress disorder and psychiatric conditions cause or contribute to hypertension.  Id.  Additionally, the appellant has submitted private medical evidence from the Veteran's physician stating that the Veteran's psychiatric condition caused increased anxiety.  See January 2008 letter from Dr. Hodsman.

In the prior remand, the Board requested that the AOJ obtain a VA medical opinion on whether the Veteran's congestive heart failure or coronary artery disease was caused or aggravated by a service-connected disability or any other aspect of his military service.  The Board asked the examiner to address the contentions in the appellant's January 2009 letter, as well as the medical treatises cited therein.  The Board also requested an opinion on whether any of the Veteran's service-connected disabilities was the principal or contributory cause of death.

The AOJ obtained a medical opinion in July 2016.  The physician opined that the Veteran's congestive heart failure and coronary artery disease were not proximately due to or the result of his burn scars or adjustment disorder.  The physician noted Dr. Hodsman's contention that the Veteran's anxiety contributed to hypertension, but stated that there is insufficient evidence that his anxiety was the primary cause of hypertension, or that hypertension was the primary cause of congestive heart failure.  The physician stated that the primary causes of hypertension are age, genetics, and weight gain.  The physician stated that congestive heart failure is generally multifactorial.  The physician then opined that the Veteran's burn scars and anxiety were not the principle or contributory causes of death.  The physician stated that there is no evidence that the burn scars the Veteran lived with for 60 years contributed to his death, and there is insufficient evidence that his anxiety contributed to his death.  

While the Board appreciates the physician's opinion, the Board finds that a supplemental opinion is needed.  The physician did not provide an opinion as to whether the Veteran's congestive heart failure or coronary artery disease was aggravated by a service-connected disability or any other aspect of his military service.  The physician also did not specifically address the medical treatises submitted by the appellant along with her January 2009 letter.  Thus, the AOJ should obtain a supplemental opinion that addresses these deficiencies.  Stegall v. West, 11 Vet. App. 268 (1998).

The Board also notes the physician's statement that there was insufficient evidence that the Veteran's anxiety was the primary cause of his hypertension or that his hypertension was the primary cause of his congestive heart failure.  In that regard, the physician left open the possibility that the Veteran's adjustment disorder may have been a causative or aggravating factor to the development of his hypertension, which in turn may have been a causative or aggravating factor to the development of his congestive heart failure or coronary artery disease.  Thus, the AOJ should ask the physician to provide an opinion on these matters.

Accordingly, the case is REMANDED for the following actions:

(Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c).  Expedited handling is requested.)

1.  Arrange for the Veteran's claims file to be reviewed by the physician who provided the March 2016 opinion for a supplemental opinion.  The physician is reminded that the Veteran was service-connected for burn scars on various areas of his body and adjustment disorder with anxiety and depression.  

The physician should provide an opinion on whether it is at least as likely as not (50 percent or greater probability) that the Veteran's congestive heart failure or coronary artery disease was caused or aggravated by (i) a service-connected disability or (ii) any other aspect of his military service.  The physician should specifically address the medical treatises submitted by the appellant along with her January 2009 letter.  

The physician should provide an opinion on whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was, in part, caused or aggravated by his service-connected adjustment disorder with anxiety and depression.

If, and only if, the physician finds that the Veteran's hypertension was, in part, caused or aggravated by his service-connected adjustment disorder with anxiety and depression, then the physician should provide an opinion on whether it is at least as likely as not (50 percent or greater probability) that the Veteran's congestive heart failure or coronary artery disease was, in part, caused or aggravated by his hypertension.

The physician should provide an opinion on whether it is at least as likely as not (50 percent or greater probability) that any of the Veteran's service-connected disabilities was the (i) principal or (ii) contributory cause of death.

The physician must provide a complete rationale for all opinions expressed.  If the physician feels that a requested opinion cannot be rendered without resorting to mere speculation, then the physician must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given the medical science and the known facts) or by a deficiency in the record or the physician (i.e. additional facts are required, or the physician does not have the needed knowledge or training).

2.  Then, readjudicate the claim.  If any decision remains adverse to the appellant, issue a supplemental statement of the case and allow the appropriate time for response.  Then, return the case to the Board.

The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West 2014).



_________________________________________________
THOMAS H. O'SHAY 
Veterans Law Judge, Board of Veterans' Appeals

Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims.  This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal.  38 C.F.R. § 20.1100(b) (2016).
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