Citation Nr: 0004116 Decision Date: 02/16/00 Archive Date: 02/23/00 DOCKET NO. 98-08 142 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE Entitlement to service connection for peripheral vascular disease. REPRESENTATION Appellant represented by: Disabled American Veterans INTRODUCTION The veteran served on active military duty from December 1952 to October 1954. This appeal arises from a March 1998 rating action of the Boston, Massachusetts, regional office (RO). In that decision, the RO denied the veteran's claim of entitlement to service connection for peripheral vascular disease. FINDING OF FACT The veteran has been diagnosed with peripheral vascular disease that has been linked to his military service. CONCLUSION OF LAW The claim of entitlement to service connection for peripheral vascular disease is well grounded. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.303 (1999). REASONS AND BASES FOR FINDING AND CONCLUSION The threshold question that must be resolved is whether the veteran has presented evidence that his claim is well grounded. See 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998); Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). A well-grounded claim is a plausible claim, one that appears to be meritorious. See Murphy, 1 Vet.App. at 81. An allegation that a disorder is service connected is not sufficient; the veteran must submit evidence in support of the claim that would "justify a belief by a fair and impartial individual that the claim is plausible." See 38 U.S.C.A. § 5107(a); Tirpak v. Derwinski, 2 Vet.App. 609, 611 (1992). The quality and quantity of the evidence required to meet this statutory burden will depend upon the issue presented by the claim. Grottveit v. Brown, 5 Vet.App. 91, 92-93 (1993). Generally, in order for a claim of service connection to be well grounded, there must be proof of present disability. Brammer v. Derwinski, 3 Vet.App. 223 (1992); see also Rabideau v. Derwinski, 2 Vet.App. 141, 143 (1992) (requiring, for a well-grounded claim, competent evidence that the veteran currently has the claimed disability). In addition, there must also be evidence of incurrence or aggravation of a disease or injury in service. Caluza v. Brown, 7 Vet.App. 498 (1995). The veteran must also submit medical evidence of a nexus between the in-service disease or injury and current disability. Id. Where the issue is factual in nature (e.g., whether an incident or injury occurred in service), competent lay testimony, including the veteran's testimony, may constitute sufficient evidence to establish a well-grounded claim; however, if the determinative issue is one of medical etiology or a medical diagnosis, competent medical evidence must be submitted to make the claim well grounded. Grottveit v. Brown, 5 Vet.App. 91, 93 (1993); Layno v. Brown, 6 Vet.App. 465, 469 (1994). A lay person is not competent to make a medical diagnosis or to relate a medical disorder to a specific cause. Espiritu v. Derwinski, 2 Vet.App. 492, 494 (1992). In support of the claim of entitlement to service connection for peripheral vascular disease, the veteran submitted copies of letters from two private physicians. The first letter is dated in September 1997, and the second one was written in the following month. Both of these letters reflect the private physicians' explanations that the veteran has "marked severe peripheral vascular disease . . . [which] has necessitated several surgical procedures and much interventional medical care over a period of many years." Additionally, the physicians concluded that "[i]t is clear from the above statements and the history given by . . . [the veteran] that his thermal injury frostbite/frostnip exposure from severe hypothermia during the Korean Conflict did indeed have a lot to do with the development of his peripheral vascular disease and the vulnerability of the tissue of his lower extremities which has developed over the past years." The physicians also stated that the veteran's "peripheral vascular disease is much more severe than it would have been otherwise and indeed necessitated his surgical intervention that otherwise may not have been necessary." A reasonable reading of the private physicians' letters is that the veteran's peripheral vascular disease is attributable to in-service events, i.e., exposure to extreme cold weather conditions which caused severe hypothermia during his Korean Conflict service. In short, these medical opinions provide evidence of current disability and nexus to military service. Consequently, the Board concludes that the veteran's claim of service connection for peripheral vascular disease is well grounded. See Caluza, supra. ORDER The claim of service connection for peripheral vascular disease is well grounded; to this extent, the appeal is granted. REMAND As noted above, a private physician stated in a September 1997 letter, and another private physician reiterated in a letter dated in the following month, that "[i]t is clear from the above statements and the history given by . . . [the veteran] that his thermal injury frostbite/frostnip exposure from severe hypothermia during the Korean Conflict did indeed have a lot to do with the development of his peripheral vascular disease and the vulnerability of the tissue of his lower extremities which has developed over the past years." Additionally, both of these physicians concluded that the veteran's "peripheral vascular disease is much more severe than it would have been otherwise and indeed necessitated his surgical intervention that otherwise may not have been necessary." Significantly, neither of the medical professionals who provided opinions or relevant history as to the onset of the veteran's peripheral vascular disease specifically stated that he had had access to the veteran's claims folder, especially pertinent medical records. In fact, both of the physicians admitted in their letters that the basis of their conclusions that the veteran's current peripheral vascular disease is associated with his exposure to extremely cold weather conditions during his Korean service was "the above statements and the history given by . . . [the veteran]." In particular, the physicians stated in their letters that the veteran "had cold injury during his exposure to extreme cold during the Korean Conflict" and that he "notes extreme sensitivity in the lower extremities since his exposure to this prolonged cold which damaged the structures of his lower extremities, because of its severity and the prolonged nature of his exposure and also the moisture involved." Review of the veteran's relevant medical records is particularly important in this case where, despite the veteran's assertions that he developed peripheral vascular disease as result of exposure to extreme cold weather conditions during his active military duty in the Korean Conflict between 1953 and 1954 and that he has continued to experience symptoms of this disorder since his Korean service, the competent evidence of record does not reflect a diagnosis of such a disability until more than 30 years after his separation from active military duty. In this regard, the Board notes that, while the service medical records which have been obtained and associated with the claims folder reflect treatment for heat rashes, the reports are negative for complaints of, treatment for, or findings of peripheral vascular disease resulting from exposure to extreme cold weather. In fact, the separation examination, which was conducted in October 1954, specifically demonstrated that the veteran had no "complaints of a medical nature" at that time and that his vascular system was normal. According to private medical reports, between August 1985 and December 1999, the veteran was treated and evaluated for severe peripheral vascular disease. In particular, these records reflect numerous surgical procedures undertaken to relieve the veteran's ischemic leg symptoms. Although two physicians recently provided opinions of a relationship between the veteran's peripheral vascular disease and his active military service, the evidence described above raises certain questions regarding the bases for such conclusions, especially in light of the absence of a diagnosis of such a disorder until more than 30 years after the veteran's separation from active duty. Consequently, the medical opinions that the veteran has peripheral vascular disease as a result of in-service exposure to extreme cold weather conditions appear to have been based solely upon the veteran's own reports of in-service events, without consideration of other relevant evidence suggesting otherwise. In order to obtain an opinion as to the onset of the veteran's peripheral vascular disease which is founded on a review of all the evidence of record, a remand is required. For the reasons stated, this case is REMANDED to the RO for the following actions: 1. The veteran should be given an opportunity to supplement the record on appeal. The RO should assist the veteran as necessary in accordance with 38 C.F.R. § 3.159 (1999). 2. Thereafter, the veteran should be afforded a VA examination to determine the presence and etiology of peripheral vascular disease. The claims folder and a copy of this remand must be made available to the examiner, the receipt of which should be acknowledged in the examination report. After reviewing the file and obtaining a detailed history from the veteran, the examiner should provide an opinion as to the medical probabilities that any peripheral vascular disease found on examination is attributable to the veteran's service (e.g., to in-service events such as exposure to extreme cold weather conditions) or to some other cause. Any opinion provided should be explained in light of the opinions already of record that the veteran's peripheral vascular disease is the result of exposure to extreme cold weather conditions during his Korean Conflict service. A complete rationale should be provided for all opinions reached. 3. The RO should thereafter re- adjudicate the issue of entitlement to service connection for peripheral vascular disease. If the benefit sought on appeal is not granted, the veteran and his representative should be provided with a supplemental statement of the case. After the veteran has been given opportunity to respond to the supplemental statement of the case, the case should be returned to the Board for further appellate consideration. The veteran need take no action until he is informed, but he may furnish additional evidence and argument while the case is in remand status. Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992); Booth v. Brown, 8 Vet. App. 109 (1995); and Kutscherousky v. West, 12 Vet. App. 369 (1999). The purpose of this remand is to comply with governing adjudicative procedures and to obtain clarifying evidence. This claim must be afforded expeditious treatment by the RO. 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 The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. THERESA M. CATINO Acting Member, Board of Veterans' Appeals