Citation Nr: 0001522 Decision Date: 01/19/00 Archive Date: 01/28/00 DOCKET NO. 95-10 386 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for a neck condition. 3. Entitlement to service connection for a skin condition, secondary to exposure to herbicides. 4. Entitlement to an increased (compensable) disability rating greater than assigned (zero percent) for the residuals of a right ankle fracture. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Vito A. Clementi, Counsel INTRODUCTION The appellant had active duty from September 1967 to July 1970, including service in Vietnam from May 1968 to May 1969. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from a January 1995 rating decision of the Houston, Texas Department of Veterans Affairs (VA) Regional Office (the RO). The Board notes that in his substantive appeal, received in March 1995, the appellant requested that he be scheduled for a personal hearing. By letter dated in April 1995, the appellant was informed that he was scheduled to present his testimony at a specified time on July 31, 1995 at the RO. In a letter dated a few days later, the appellant was advised that the RO was moving its location, and that his hearing would be held at its new site. In a July 31, 1995 report of contact memorandum, the appellant was reported to have notified the RO that he desired to withdraw his appeal as to all of the issues then under consideration. In a statement by his accredited representative dated in April 1997, the appellant reiterated that he desired to withdraw his appeal. However, his representative reported that the appellant would not reduce this desire to writing. The record further reflects that RO personnel attempted to contact the appellant in January 1999 to schedule the appellant for a Travel Board hearing. It was noted that a previous attempt to contact the appellant had been made in December 1998. On both these occasions, the RO recorded a telephonic message for the appellant. The appellant did not respond to either of these inquiries. By letter dated in March 1999 and forwarded to the appellant at an updated address, the appellant was notified that he had been scheduled for a Travel Board hearing for April 15, 1999. The appellant did not appear for the hearing, and the notification letter was not returned as undelivered. In this regard, the Board presumes that the appellant received the notification letter. See Leonard v. Brown, 10 Vet. App. 315, 316 (1997); YT v. Brown, 9 Vet. App. 195, 199 (1996). Although the appellant has expressed a desire to withdraw his appeal, such action may not be accomplished absent such expression in writing. See 38 C.F.R. § 20.204 (1999). Although the appeal must therefore proceed, the facts of record as to the procedural history of this case indicate that the appellant is unwilling to participate further in the necessary preliminary inquiry with regard to his claims. The Board therefore is of the opinion that the appellant's claims have been developed to the maximum feasible attempt, and will therefore proceed to a review on the merits. FINDINGS OF FACT 1. The available evidence does not support a finding that the appellant is a combat veteran. 2. The available evidence does not reflect that the appellant sustained a qualifying stressor during the course of his military service. 3. Competent medical evidence has not been adduced to establish a current diagnosis of a neck disability or any medical nexus between any claimed neck disability and the appellant's military service. 4. Competent medical evidence has not been adduced to establish a current diagnosis of a dermatological disorder or any medical nexus between any claimed dermatological disorder and the appellant's military service. 5. The appellant has failed without good cause to report for a VA medical examination to ascertain the severity of his right ankle disability. CONCLUSIONS OF LAW 1. PTSD was not incurred in or as a result of the appellant's active military service. 38 U.S.C.A. §§ 1110, 1154 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). 2. The appellant's claim of service connection for a neck disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The appellant's claim of service connection for a skin disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. Entitlement to an increased rating for a right ankle disability cannot be established without a current VA examination; as the appellant has failed to report for such examination without good cause, the claim is denied. 38 C.F.R. §§ 3.327, 3.655 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant contends that he has PTSD and a neck condition that were caused by incidents of his military service. He further contends that he has a skin disorder that was caused by in-service exposure to an herbicide, Agent Orange. He has also challenged the RO's January 1995 rating decision with respect to the assigned rating for a right ankle disorder. By law, the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990); 38 U.S.C.A. § 7104(d)(1) (West 1991). With this requirement of law, and in light of the appellant's contentions, a brief factual review of evidence of record as found in the appellant's claims folder would be helpful to an understanding of the Board's decision. The Board will then review the applicable law in the context of its disposition of each of the appellant's claims. Additional facts and law will be discussed where appropriate in the context of each individual issue on appeal. Entitlement to service connection for PTSD Factual background The appellant's report of separation from the Armed Forces reflects that he is the recipient of the National Defense Service Medal, the Vietnam Service Medal with 3 Bronze Service Stars, the Republic of Vietnam Campaign Medal, and the Air Medal. His report of separation further reflects that during the course of his military service, he held military occupational specialties of aircraft maintenance crewman and single rotor-turbo helicopter maintenance specialist. While assigned to Vietnam, the appellant served as a crew chief. The appellant's record of assignments further reflect that he participated in some capacity during Vietnam counteroffensives phases I and V, and in an "unnamed campaign." The appellant's service medical records are devoid of any mention of psychiatric complaints, symptoms or diagnoses. There are no references to psychiatric problems for decades after he left service. The appellant sought service connection for a claimed psychiatric disorder by application received in May 1994. During the following month, the appellant was requested by letter to provide substantiating and clarifying detail as to his claimed in-service stressful events, his employment history, and other data relevant to the development of his claimed PTSD. The appellant underwent a VA physical examination in February 1994. The appellant reported alcohol abuse, "chronic problems related to Vietnam memories and poor employment." He was diagnosed to have alcohol dependence and marijuana abuse. The appellant underwent a VA psychiatric examination in October 1994. He reported frequent nightmares about Vietnam, and stated that he was homeless for a period because he did not have to encounter other persons. He reported that once while sleeping, he had a nightmare about an occasion when his helicopter was shot down, and he and the crew were forced to "hide out in the jungle" from the enemy. He recounted that in his nightmare, after his crew made their way back to a fire base, an enemy mortar shell hit the shelter where he and his crew had sought refuge. The appellant reported that in addition to being trained in helicopter maintenance, he also flew a helicopter, and did so during the "Tet Offensive." He stated that at other times, he also served as a "door gunner." The appellant was diagnosed to have PTSD, and alcohol and cannabis dependence in remission. In May 1997, RO personnel determined that the appellant's account of his claimed stressors as was outlined during the October 1994 VA examination was insufficient. He was again requested to provide substantiating information. There was no response to this letter. Relevant law and regulations Service connection - in general In general, service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 1991). The resolution of this issue must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which the claimant served, his medical records and all pertinent medical and lay evidence. Determinations relative to service connection will be based on review of the entire evidence of record. 38 U.S.C.A. § 7104(a) (West 1991); 38 C.F.R. § 3.303(a); see also Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Under pertinent law and VA regulations, service connection may be granted if the evidence establishes that a psychiatric disability was incurred in service, or was manifested to a compensable degree within one year after service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.303(a), 3.307, 3.309 (1999). Notwithstanding the lack of a diagnosis of a psychiatric disorder during service or within one year thereafter, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 1991); 38 C.F.R. § 3.303(d) (1999); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). Service connection - PTSD Service connection for PTSD requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressors actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressors. 38 C.F.R. § 3.304(f). With regard to the second criterion, the evidence necessary to establish that the claimed stressor actually occurred varies depending on whether it can be determined that the veteran "engaged in combat with the enemy." 38 U.S.C.A. § 1154(b) (West 1991); 38 C.F.R. § 3.304(d) (1999); see also Gregory v. Brown, 8 Vet. App. 563 (1996); Collette v. Brown, 82 F.3d 389 (Fed.Cir. 1996). In Zarycki v. Brown, 6 Vet. App. 91 (1993), the United States Court of Appeals for Veterans Claims (the Court) set forth the analytical framework and line of reasoning for determining whether a veteran was exposed to a recognizable stressor during service. The Court in Zarycki noted that, under 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) and (f), the evidence necessary to establish the incurrence of a recognizable stressor during service to support a claim of service connection for PTSD will vary depending on whether the veteran "engaged in combat with the enemy." See Hayes v. Brown, 5 Vet. App. 60 (1993). The determination as to whether the veteran "engaged in combat with the enemy" is made by considering military citations that expressly denote as much and/or other service department or lay evidence that is credible. See Doran v. Brown, 6 Vet. App. 283, 289 (1994). Well grounded claims Under 38 U.S.C. A. § 5107(a), an applicant for VA benefits has the "burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded," meaning that the claim is "one which is . . . capable of substantiation." Further, the claim "need not be conclusive but only possible" in order meet the burden established in the statute. Kandik v. Brown, 9 Vet. App. 434, 439 (1996). The burden to submit evidence sufficient to establish a "well-grounded" claim is the claimant's alone. Epps v. Gober, 126 F.3d 1464, 1469 (Fed.Cir. 1997). It has been observed that in Epps, the Federal Circuit Court of Appeals "definitively held that 'there is nothing in the text of [38 U.S.C.A] § 5107 to suggest that [] VA has a duty to assist a claimant until the claimant meets his or her burden'" of establishing a well-grounded claim before providing any assistance to the claimant." Morton v. West, 12 Vet. App. 477, 481 (1999) (emphasis added). It was also noted that the claimant's burden to produce evidence to render a claim well grounded was a "condition precedent established by Congress" that neither VA nor the Court was free to ignore. Morton, 12 Vet. App. at 485. In order for the appellant's claim to be well grounded, there must have been presented competent evidence of a current disability; a disease or injury which was incurred in service, and a nexus between the disease or injury and the current disability. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir. 1996)(table); see Watai v. Brown, 9 Vet. App. 441, 443 (1996). In ascertaining whether a claim is well grounded, the truthfulness of evidence proffered in its support is presumed. King v. Brown, 5 Vet. App. 19, 21 (1993). Failure to report for VA examination VA regulations provide that when entitlement or continued entitlement to a VA benefit cannot be established or confirmed without a current VA examination or reexamination and a claimant, without good cause, fails to report for such examination, or reexamination, action shall be taken in accordance with paragraph (b) of 38 C.F.R. § 3.655 as appropriate. When a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the claimant fails to report for an examination scheduled in conjunction with a claim for increase, the claim shall be denied. 38 C.F.R. § 3.655(b). Analysis Initial matters - well groundedness of the claim/duty to assist/standard of proof As discussed in detail above, a veteran seeking service connection for PTSD must satisfy the initial burden of submitting a well-grounded claim by furnishing (1) medical evidence of a current disability, (2) medical or lay evidence of an in-service stressor, and (3) medical evidence of a nexus between service and the current PTSD disability. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128, 136- 137 (1997). Having carefully reviewed all of the evidence of record and presumed it credible, the Board finds that the appellant has submitted a well-grounded claim of entitlement to service connection for PTSD. Through the opinion of the October 1994 VA examiner, the appellant has proffered a diagnosis of PTSD, linked to the appellant's reported history of service Vietnam." In particular, the Board again observes that the appellant's report of the relevant Vietnam experiences is presumed credible at this predicate stage of analysis. King, supra. Having found that the appellant's claim is well grounded does not end the Board's inquiry. Rather it places upon VA the duty to assist the appellant in the development of the claim by obtaining relevant records which could possibly substantiate the claim and conducting appropriate medical inquiry. See Peters v. Brown, 6 Vet. App. 540, 542 (1994); see 38 U.S.C.A. § 5107(a). It is now well-settled that "[t]he duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991); see Hayes v. Brown, 5 Vet. App. 60, 68 (1993). In this case, as discussed above, the appellant has foreclosed all further inquiry with regard to the claimed psychiatric (and other) disorders, in that he failed to respond to the RO's inquiry concerning his alleged stressors and he failed to report for a travel Board hearing, and in so doing has not fulfilled his responsibility to cooperate with VA's efforts to develop his claim. When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. In Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990), the United States Court of Veterans Appeals (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. See also Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Discussion The law and regulations pertaining to service connection for PTSD have been set out in detail above. In essence, for a grant of service connection for PTSD, the governing regulation, 38 C.F.R. § 3.304(f), requires the presence of three elements: (1) A current, clear medical diagnosis of PTSD; (2) credible supporting evidence that the claimed in- service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in-service stressor. Cohen, 10 Vet. App. at 138. Regarding the initial § 3.304(f) PTSD element, if there is a current, clear, and unequivocal diagnosis of record from a mental-health professional, it is presumed to have been made in accordance with the applicable DSM criteria as to both the adequacy of the symptomatology and the sufficiency of the stressor. See Cohen, 10 Vet. App. at 140. In this matter, the appellant has been diagnosed to have PTSD by Dr. J.G. As to the second §3.304(f) element, as discussed above the evidence necessary to establish the occurrence of a recognizable stressor during service varies depending on whether or not the veteran was "engaged in combat with the enemy." West v. Brown, 7 Vet. App. 70, 76 (1994). The Board is required to "make specific findings of fact as to whether or not the veteran was engaged in combat with the enemy and, if so, whether the claimed stressor is related to such combat." Zarycki v. Brown, 6 Vet. App. 91, 98 (1996). If the claimed stressor is not combat related, "the veteran's lay testimony regarding [an] in-service stressors is insufficient, standing alone, to establish service connection and must be corroborated by "credible evidence," Doran v. Brown, 6 Vet. App. 283, 289 (1994). Applicable law further provides that where it is determined, through the receipt of certain recognized military citations or other supportive evidence, that the veteran was engaged in combat with the enemy and the claimed stressors are related to such combat, the appellant's lay testimony regarding the stressors must be accepted as conclusive as to their actual occurrence and no further development for corroborative evidence will be required, provided that the appellant's testimony is found to be "satisfactory." Satisfactory evidence is "credible" and "consistent with the circumstances, conditions, or hardships of such service." 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). In Kessel v. West, 13 Vet. App. 9 (1999), the Court observed that the import of the statute is ascertained when viewed in the context of comparing the evaluation of the merits of the claim of a non-combat veteran and a combat veteran. A non- combat veteran's claim must be denied if the preponderance of the evidence is against the claim. By preponderance of the evidence is meant that the truth of the fact in controversy is "more likely than not." See Aguilar v. Derwinski, 2 Vet. App. 21, 23 (1991). Conversely, a combat veteran's claim cannot be denied unless there is "clear and convincing evidence" to the contrary as to the service incurrence or aggravation element. By "clear and convincing" is meant that there is a "reasonable certainty of the truth of the fact in controversy." See Vanerson v. West, 12 Vet. App. 254 (1999). In short, in order to grant service connection for PTSD to a non-combat veteran, there must be credible evidence to support the veteran's assertion that the stressful event occurred. Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in- service stressors. Cohen, 10 Vet. App. at 142; Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996). Having carefully reviewed all of the evidence of record as to this aspect of the appellant's claim, the Board finds that the appellant is not a combat veteran and the presumptive provisions of 38 U.S.C.A § 1154(b) are not applicable. First, having carefully scrutinized the appellant's service records, the Board notes that the appellant has not been awarded any combat-related awards or decorations. In particular, although the appellant was awarded the Air Medal, it is not accompanied by a "V" device, indicating its award for valor in combat service. Further, although the appellant's service personnel record reflects that he was present and participated in some aspect of the Vietnam Counteroffensives Phases I and V, as well as an unnamed campaign, there is no indication of the nature of his duties apart from his performance of his general duties. The Board emphasizes that in this assessment, it notes that despite repeated attempts by the RO to obtain clarifying information as to the appellant's claimed stressors, the appellant has steadfastly refused to cooperate in this endeavor. Based in large part upon this lack of information, the record does not therefore indicate that the appellant is a veteran of combat. See VAOPGCPREC 12-99, (October 18, 1999) [holding that the determination of whether a veteran "engaged in combat with the enemy" depends on multiple factors, including the requirement that the veteran participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. The issue of whether any particular set of circumstances constitutes engagement in combat with the enemy for purposes of section 1154(b) must be resolved on a case by case basis.]. As is alluded to above, if the claimed stressor is not combat-related, "the veteran's lay testimony regarding [an] in-service stressors is insufficient, standing alone, to establish service connection and must be corroborated by 'credible evidence,' " Doran v. Brown, 6 Vet. App. 283, 289 (1994); see also Kessel, supra. In this matter, the appellant has reported during the conduct of a VA medical examination that he was involved in an episode where his helicopter was shot down, and he was forced to evade enemy soldiers. The appellant has not proffered any additional details as to the time, place or other circumstances surrounding this alleged event, which cannot be further substantiated absent the appellant's cooperation with VA's efforts. The appellant's service medical records are devoid of any reference to the occurrence of this claimed event, or of any injuries that might have then been sustained, and the appellant has not furnished any particulars concerning that event. To the extent that the appellant's service medical records document any incident resembling such occurrence, they merely reflect that in October 1968, the appellant complained of some ear "popping" after his aircraft made a precipitous decline. There is no reference in these records to any incident of the appellant's aircraft's crashing. The appellant's statements concerning his experiences in Vietnam are vague and nonspecific as to "who, what, when and where" of the claimed incidents. As noted above, the appellant has consistently refused to provide further information as to his claimed stressors, requisite to VA's efforts to assist him in the development of his claim. As alluded to earlier, the King presumption of credibility does not attach once a claim has been determined to be well grounded, as here. The Board observes that the VA examiner apparently believed the appellant to be a veteran of combat. However, a physician's opinion is irrelevant as to the question of the occurrence of the claimed stressors. See Cohen, 10 Vet. App. at 142; Moreau,9 Vet. App. at 395-396. See also Swann v. Brown, 5 Vet. App. 229, 233 (1993) [medical opinion based solely or in large measure on a veteran's reported medical history will not be probative to disposition of claim if the objective evidence does not corroborate the reported medical history or if a preponderance of the evidence is otherwise against the claim]. In summary, for the reasons and bases discussed in detail above, the Board concludes that the preponderance of the evidence is against the claim with regard to the issue of the occurrence of a qualifying stressor. Service connection for PTSD is therefore denied. Entitlement to service connection for a neck condition Factual background The appellant's service medical records reveal no complaints, symptoms or diagnoses of a cervical injury or disorder. There is no reference to any other injury. During an October 1994 VA physical examination, the appellant reported that he was involved in a helicopter crash in 1968 and that he then injured his neck. He stated that he did not seek medical help after his separation from service. He stated that he believed he had arthritis in the shoulder. It was noted that the appellant had been hospitalized from January through February 1994 for a right rotator cuff injury, among other disorders. The examiner stated that the appellant had full range of motion in his cervical spine and both shoulders, but that the appellant reported some pain on motion. The appellant was scheduled for a VA orthopedic examination in May 1999. He did not report for the examination. Analysis As is noted above, it is the appellant's burden alone to submit evidence of a well-grounded claim. Reiterating, he must present competent evidence of a current disability; a disease or injury which was incurred in service, and a nexus between the disease or injury and the current disability. Caluza, 7 Vet. App. at 506. Further reiterating, the factual accounts of claimants as to the incurrence of service- connected disabilities are generally presumed credible for the limited purpose of ascertaining whether the claim is well grounded. King, supra. Applying Caluza to the facts of this case, the Board concludes that the appellant's statements as to an in-service neck injury, which must be presumed to be credible under King, are sufficient to arguably satisfy the second Caluza element, in-service injury. As to the first Caluza element, a current disability, no current disability of the cervical spine has been diagnosed. The appellant has complained of neck pain, but there is no medical diagnosis of a neck condition. The Board notes that the evidence suggests that the appellant was hospitalized in 1994 for a shoulder, not a neck, problem. In any event, there is no recent medical evidence of a diagnosed neck disability. As indicated above, the appellant failed to report for a May 1999 VA examination. Under 38 C.F.R. § 3.655, the Board must decide this claim on the evidence of record. In Brammer v. Derwinski, 3 Vet. App. 223 (1992), the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. In Rabideau v. Derwinski, 2 Vet. App. 141 (1992), the Court held that the failure to demonstrate that a disability is currently manifested constitutes failure to present a plausible or well-grounded claim. Moreover, there has not been presented a competent medical opinion linking the appellant's claimed neck condition to any incident of his military service. In this regard, the Board has carefully examined the October 1994 VA examination, and notes that the examining physician did not express an opinion as to whether the appellant's unspecified neck pain was linked to military service. Indeed, the examiner specifically noted that the "neck injury [was] claimed as service connected" without further comment. The appellant's own statements cannot supply a competent medical diagnosis of a current medical disability, its date of onset, or its etiology. These matters can only be established by competent medical evidence. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992); Grottveit v. Derwinski, 5 Vet. App. 91, 93 (1993). Thus, there is no evidence of a current disability and no medical nexus evidence of record. The Court has held that "[i]n the absence of competent medical evidence of a current disability and a causal link to service or evidence of chronicity or continuity of symptomatology, a claim is not well grounded." Chelte v. Brown, 10 Vet. App. 268 (1997). In summary, after having carefully examined the evidence of record, the Board finds that the appellant has not presented a well-grounded claim of entitlement to service connection for a neck disability. Service connection for a neck disability is accordingly denied. Additional comments The Board has considered whether remand of this matter for further medical development is warranted. See Engelke v. Gober, 10 Vet. App. 396, 399 (1997). However, because the appellant's claim is not well grounded, he is not entitled to VA assistance in its development. The Board has examined all evidence of record with a view towards determining whether the appellant has notified VA of the possible existence of information which would render his claim plausible. However, the Board finds no such information. See Beausoleil v. Brown, 8 Vet. App. 459, 464- 465 (1996); Robinette v. Brown, 8 Vet. App. 69, 80 (1995). Entitlement to service connection for a skin condition, secondary to herbicidal exposure. Factual background As noted above, the appellant served for a year in Vietnam. The appellant's service medical records reveal no complaints, symptoms or diagnoses of a dermatological condition. In February 1994, the appellant was hospitalized at a VA facility after a drinking binge. Warty growths were noted and removed from the face and arms with liquid nitrogen. Discharge diagnoses included actinic keratoses. The appellant underwent a VA physical examination in October 1994, with specific inquiry towards whether he had any disorders associated with herbicidal exposure. He stated that he had been previously treated for actinic keratosis, and that he believed it to be the result of in-service exposure to "Agent Orange." The appellant also stated that he had "damage to nerves," also caused by exposure to the herbicide. In relevant part, the examiner diagnosed the appellant to have a history of several removed "skin cancers," but stated that he had no chloracne and no scars related to chloracne. The examiner further stated that the appellant's claimed disorders had "no relationship" to herbicidal exposure. Relevant law and regulations The law and regulations pertaining to service connection generally and to well grounded claims have been set forth above and will not be repeated here. Service connection - Agent Orange Applicable regulations provide that a veteran who, during active service, served in the Republic of Vietnam during the Vietnam era, and has a disease listed at 38 C.F.R. § 3.309(e) shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that he was not exposed to any such agent during service. Regulations provide, in pertinent part, that if a veteran was exposed to an herbicide agent (such as Agent Orange) during active military, naval, or air service, the following diseases shall be service- connected if the requirements of § 3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of § 3.307(d) are also satisfied.: Chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; multiple myeloma; non- Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); soft- tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). The term "soft-tissue sarcoma" includes the following: adult fibrosarcoma; dermatofibrosarcoma protuberans; malignant fibrous histiocytoma; liposarcoma; leiomyosarcoma; epithelioid leiomyosarcoma (malignant leiomyoblastoma); rhabdomyosarcoma; ectomesenchymoma; angiosarcoma (hemangiosarcoma and lymphangiosarcoma); proliferating (systemic) angioendotheliomatosis; malignant glomus tumor; malignant hemangiopericytoma; synovial sarcoma (malignant synovioma); malignant giant cell tumor of tendon sheath; malignant schwannoma including malignant schwannoma with rhabdomyoblastic differentiation (malignant Triton tumor), glandular and epithelioid malignant schwannomas; malignant mesenchymoma; malignant granular cell tumor; alveolar soft part sarcoma; epithelioid sarcoma; clear cell sarcoma of tendons and aponeuroses; extraskeletal Ewing's sarcoma; congenital and infantile fibrosarcoma; malignant ganglioneuroma. 38 C.F.R. § 3.309(e). The United States Court of Appeals for the Federal Circuit has held that when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994), reversing in part Combee v. Principi, 4 Vet. App. 78 (1993). As such, the Board must not only determine whether the veteran has a disability which is recognized by VA as being etiologically related to prior exposure to herbicide agents that were used in Vietnam (See 38 C.F.R. § 3.309(e)), but must also determine whether his current disability is the result of active service under 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.303(d). In other words, the fact that the veteran does not meet the requirements of 38 C.F.R. § 3.309 does not in and of itself preclude him from establishing service connection as he may, in the alternative, establish service connection by way of proof of actual direct causation, showing that his exposure to an herbicide during service caused any current disorders. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(d). However, where the dispositive issue involves a question of medical causation (such as whether a condition claimed is the result of active service in the military), then competent medical or other probative evidence is necessary to render the claim plausible or well grounded. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In November 1999 the Secretary of Veterans Affairs (Secretary) determined that there is no positive association between herbicide exposure and any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See Diseases Not Associated With Exposure to Certain Herbicide Agents, 64 Fed. Reg. 59232-59243 (November 2, 1999). Additionally, it has been held that in order to be entitled to the presumption of service connection for herbicide exposure, the veteran must have been diagnosed to have one of the conditions enumerated in either 38 U.S.C.A § 116(a) or 38 C.F.R. § 3.309(e). McCartt v. West, 12 Vet. App. 164, 168 (1999). Analysis As an initial matter, there is no medical evidence which indicates that the appellant has a skin disorder. The Board notes in this regard that actinic keratoses were removed during the February 1994 VA hospitalization, but in October 1994, the VA examiner made no reference to any current skin disorder. It was further noted that the appellant had no chloracne or scars. In this respect, the appellant does not have a current disability. As discussed above, the law limits entitlement for service- related diseases and injuries to cases where the underlying in-service incident has resulted in a disability. Absent a currently manifested disability, the claim is not well grounded. See Brammer and Rabideau, supra. The Board additionally notes in passing that even if actinic keratoses currently exist, such is not listed as a presumptive Agent Orange disease. Under such circumstances, the appellant's mere presence in Vietnam does not suffice to support a finding that he was exposed to an herbicidal agent. See McCartt, supra. Additionally, there is of record no medical nexus evidence linking the now-removed actinic keratoses and the appellant's military service, including his service in Vietnam. Indeed, a VA physician stated in October 1994 that there was "no relationship to Agent Orange exposure". Accordingly, the remaining two prongs of the Caluza well groundedness analysis have also not been met. In short, after having carefully examined the evidence of record, the Board finds that the appellant has not presented a well-grounded claim of entitlement to service connection for any dermatological disorder. The appellant's claim is therefore not well grounded and is denied. Entitlement to a disability rating greater than zero percent for the residuals of a right ankle fracture. The appellant's service medical records reveal that in December 1967, he twisted his ankle and sustained a chip fracture of the distal fibula. He was placed in a short leg cast. Approximately a month later, he was noted to be "doing well, although the ankle was still tender. His separation physical examination reveals no complaints relative to his right ankle. There is no medical evidence referable to the appellant's right ankle for decades after service. He was hospitalized at a VA facility in February 1994. Several medical problems were addressed during the hospitalization; a right ankle disability was not mentioned. During the October 1994 VA examination, a right ankle problem was neither mentioned or diagnosed. By rating decision dated in January 1995, service connection was granted for the residuals of a right ankle fracture and a zero percent disability evaluation was assigned. That decision appears to have been based strictly on the service medical records from decades earlier. There is no subsequent medical evidence relating to a right ankle disability. As noted above, the appellant was scheduled for a VA orthopedic examination in May 1999. He did not report for the examination. Relevant law and regulations Disability determinations are determined through the application of a schedule of ratings, which is predicated upon the average impairment of earning capacity. Separate diagnostic codes identify various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321(a) and Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. VA regulations specifically require the performance of a new medical examination under certain circumstances. "Reexaminations . . . will be requested whenever VA determines there is a need to verify . . . the current severity of a disability." 38 C.F.R. § 3.327. In assessing the current severity of a disability, "reexaminations will be required if . . . evidence indicates there has been a material change in a disability or that the current rating may be incorrect." Id. When entitlement to a benefit, such as an increased rating, cannot be established or confirmed without a current VA examination or re-examination, and a claimant without good cause fails to report for such an examination, or re- examination, the claim shall be denied. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, or the death of an immediate family member. 38 C.F.R. § 3.655(a),(b); Engelke v. Gober, 10 Vet. App. 396, 399 (1998). Analysis Initially, the Board has determined that this issue is a matter in which the law, as opposed to the evidence, is dispositive. The United States Court of Appeals for Veterans Claims (Court) has observed that the use of the statutory term "well grounded" should be confined to matters in which the evidence is dispositive. Therefore, in cases such as this, where the law and not the evidence is dispositive, the claim should be denied or the appeal to the Board terminated because of the absence of legal merit or the lack of entitlement under the law (Cf. FED R. CIV. P. 12(b)(6) ("failure to state a claim upon which relief can be granted"), as opposed to dismissing the case for failure to present a well-grounded claim. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The dispositive law in this case is 38 C.F.R. § 3.655. This regulation states, "[w]hen a claimant fails to report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. When the examination was scheduled in conjunction with any other original claim, a reopened claim for a benefit which was previously disallowed, or a claim for increase, the claim shall be denied." 38 C.F.R. § 3.655(b) [emphasis added by the Board]. Examples of "good cause" include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. 38 C.F.R. § 3.655(a). In this case, the record reflects that the appellant failed, without explanation, to report for a VA examination which was scheduled in May 1999. This VA examination was specifically scheduled to assist him in the development and adjudication of the claim now on appeal. No specific reason has been given by the appellant concerning his failure to report for the scheduled VA examination. The Board observes that there is absolutely no medical evidence pertaining to the claimed ankle disability since the appellant left military service in July 1970, almost three decades ago. Thus, there is no medical evidence of record which would serve as a viable substitute for the scheduled examination. See 38 C.F.R. § 3.326(b). In a case such as this, where additional development is required to determine entitlement to increased benefits, the appellant may not passively sit by under circumstances where his cooperation is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). In such a situation, the Board has no alternative but to deny the appellant's claims as provided under the provisions of 38 C.F.R. § 3.655. Accordingly, the appropriate disposition of the appellant's claim of entitlement to an increased disability rating for his service-connected right ankle disability is denial because of his failure to report for examination without good cause. In a case such as this in which the law and not the evidence is dispositive, the claim must be denied because of the absence of legal merit or the lack of entitlement under law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). For the reasons and based expressed above, the claim is denied. ORDER Service connection for PTSD is denied. A well-grounded claim not having been presented, service connection for a neck condition is denied. A well-grounded claim not having been presented, service connection for a skin condition is denied. An increased disability for residuals of a right ankle fracture is denied. Barry F. Bohan Member, Board of Veterans' Appeals The National Defense Service Medal is awarded for honorable active service for any period between June 27, 1950 and July 27, 1954, or between January 1, 1961 and August 14, 1974. See Manual of Military Decorations and Awards, 6-1 (Department of Defense Manual 1348.33-M, July 1990). The Vietnam Service Medal is awarded to all members of the Armed Forces of the United States serving at any time between July 4, 1965 and March 28, 1973 in Thailand, Laos, or Cambodia or the airspaces thereover in direct support of operations in Vietnam. Id. at 6-1. An award of a Bronze Service Star for the Vietnam Service Medal is based upon "participation during" approved campaign periods." Id. at 6-6. The Republic of Vietnam Campaign Medal is awarded to those personnel who (1) served in the Republic of Vietnam for 6 months during a specified period; or, (2) served outside the geographical limits of the Republic of Vietnam but contributed direct combat support to the Republic of Vietnam and Armed Forces for 6 months; or, (3) served in the Republic of Vietnam or outside its geographical limits for less than 6 months but were wounded, captured or killed. See Army Regulation 672-5-1, 28. The Air Medal is awarded to any person who, while serving in any capacity in or with the U.S. Army, shall have distinguished himself by meritorious achievement while participating in aerial flight. Awards may be made to recognize single acts of merit or heroism, or for meritorious service. See id., at 15. The Board observes that the "stressor letter" was forwarded to a post office box address, as specified by the appellant in his claim for service connection. Following the receipt of his January 1995 Notice of Disagreement, the appellant was forwarded a Statement of the Case at the previously designated address. In his substantive appeal, the appellant did not report a current address. The record further reflects that the appellant was sent a second "stressor letter" in May 1997, and a third in July 1997 to a new address after it had been ascertained that the appellant had moved without informing the RO of his whereabouts. A report of contact memorandum dated in October 1997 reflects that the appellant reported receiving the July 1997 letter, and that he further reported that he responded to it. He further indicated that he was "tired of [VA's] letters and [VA] losing his mail." By letter dated in December 1997, the appellant was again contacted by VA personnel, (apparently and specifically, the same individual who spoke with the appellant in October 1997), and was informed that his response to the July 1997 letter had not been received. There was no further response to the RO's inquiry. "Actinic" refers to rays of light beyond the violet end of the spectrum that produce chemical effects, i.e., radiation. See Hardin v. West, 11 Vet. App. 74, 76 (1998) [citing Dorland's Illustrated Medical Dictionary 21 (28th ed. 1994).]