Citation Nr: 0002674 Decision Date: 02/03/00 Archive Date: 02/10/00 DOCKET NO. 94-35 735 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for residuals of lead poisoning, including diabetes mellitus, angina, degenerative disc disease, hypertension, bilateral visual impairment, paralysis of the hands and feet extending to the knees, impaired memory, a nervous disorder, impaired kidney and bowel function, and bilateral defective hearing. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Richard E. Coppola, Counsel INTRODUCTION The veteran had active service from October 1955 to October 1957. This matter is before the Board of Veterans' Appeals (Board) on appeal of a February 1994 rating decision from the Nashville, Tennessee Department of Veterans Affairs (VA) Regional Office (RO), wherein the RO denied entitlement to service connection for the multiple disorders at issue claimed as secondary to lead poisoning. The Board remanded the case to the RO for further development and adjudicative actions in February 1997. In June 1999 the RO affirmed the denial of entitlement to service connection for the multiple disorders at issue claimed as secondary to lead poisoning. The case has been returned to the Board for further appellate review. FINDING OF FACT The claim of entitlement to service connection for diabetes mellitus, angina, degenerative disc disease, hypertension, bilateral visual impairment, paralysis of the hands and feet extending to the knees, impaired memory, a nervous disorder, impaired kidney and bowel function, and bilateral defective hearing as secondary to lead poisoning is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. CONCLUSION OF LAW The claim of entitlement to service connection for diabetes mellitus, angina, degenerative disc disease, hypertension, bilateral visual impairment, paralysis of the hands and feet extending to the knees, impaired memory, a nervous disorder, impaired kidney and bowel function, and bilateral defective hearing as secondary to lead poisoning is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION Factual Background The claims folder does not include the veteran's service medical records. In January 1984, the RO requested the veteran's separation documents from the National Personnel Records Center (NPRC). The NPRC responded that the veteran's service personnel records could not be located and may have been destroyed by a fire at that facility in 1973. In connection with the present claim for service connection, the RO requested the veteran's service medical records from the NPRC in August 1993. The NPRC responded that the veteran's service medical records could not be located and may have also been destroyed in the 1973 fire. The NPRC also responded that there were no available records from the Office of the Surgeon General. The NPRC notified the RO that additional information was needed in order to conduct an organizational search for treatment records from the veteran. The RO requested the veteran by letter to provide specific information as to when and through which organization he received treatment for lead poisoning during active service. The veteran responded in January 1994 that he "received no treatment for lead poisoning in service. I first learned I had lead poisoning when I went to the VA hospital at Memphis in 1972." The RO forwarded NA Form 13055 to the veteran in June 1997 in order to obtain information regarding exposure to lead poisoning during service. The veteran responded later that month, indicating that treatment during active service was unknown. The veteran filed an application for nonservice-connected disability pension benefits in November 1983. He reported that he was unemployed secondary to lead poisoning incurred on August 8, 1972. The veteran reported having received no treatment for lead poisoning during service. An October 1983 statement from the veteran's treating physician certifies that the veteran had been receiving treatment for degenerative disc disease (DDD), diabetes, angina pectoris and hypertension for many years. The examiner also noted that the veteran had anxiety. The examiner stated that the veteran was unemployable at that time. This examiner submitted another statement in August 1993. The veteran filed an application for service-connected disability compensation benefits in August 1993. He reported that he incurred multiple disabilities as a result of lead poisoning during active service. He reported that he could not remember having received treatment for lead poisoning during service. The veteran underwent several VA medical examinations in September 1993. The report of the general medical examination includes diagnoses of high blood pressure, diabetes mellitus and neuropathy of the extremities, which the examiner described as diabetic versus plumbism. The examiner asked the veteran whether his history of paralysis of the lower extremities in 1972 was due to diabetes. The veteran responded that he was told that the paralysis was due to lead poisoning. The examiner also diagnosed low back pain/strain versus degenerative joint disease (DJD) affecting sciatica. X-ray examination showed spondylosis of the lumbar spine and sclerosis, which the examiner indicated was presumably a reaction to DJD. X-ray examination also showed osteoarthritis of the hips and knees. On the authorized audiological evaluation in September 1993, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 20 25 20 LEFT 10 15 20 30 25 Speech audiometry revealed speech recognition ability of 98 percent in the right ear and of 100 in the left ear. The examiner reported that the veteran's bilateral hearing acuity was essentially normal. On VA neurological evaluation in September 1993 the veteran related a history of lead poisoning in 1955. He stated that he had had numbness in his extremities since that time. The veteran also complained of weakness and muscle atrophy in his hands and feet, as well as progressive difficulty remembering things since 1955. The examiner performed a physical examination and referred the veteran for nerve conduction studies. The diagnoses were painful peripheral neuropathy due to diabetes and lead poisoning, mild dementia by history, hypertension, anxiety disorder, status post stab wound to the abdomen and coronary artery disease (CAD). On VA visual evaluation in September 1993, the veteran related a 20-year history of diabetes mellitus and he complained of off-and-on fluctuating visual acuity. Based on the examination, the diagnoses were no background diabetic neuropathy and probable mild ocular hypertension. The veteran submitted a November 1972 medical statement from his then treating physician. It shows he had a severe polyneuropathy with atrophy in all four extremities and was considered totally disabled at that time. The veteran also submitted pictures showing he participated in an artillery unit during active service and a statement from a fellow serviceman, which relates that some members of their unit incurred lead poisoning from handling the ammunition and from cleaning the gun. In February 1997 the Board remanded the case to the RO for further development and adjudicative actions. The RO obtained private inpatient and outpatient treatment records dated from September 1972 to January 1973. The records show the veteran was originally admitted from April 1972 to September 1972 because of multiple peripheral neuropathy, which had been confirmed on electromyography (EMG) testing. He was again admitted in September 1972 and underwent examination and testing. The examiner diagnosed this as polyneuropathy of some type. The veteran showed subjective improvement at discharge, but was seen in October 1972 because of persistent polyneuropathy. The veteran reported slight improvement referable to the peripheral neuropathy in January 1973, but he complained of continued weakness in all extremities. The examiner diagnosed flu syndrome. The RO also obtained VA inpatient and outpatient treatment records dated from April 1973 to December 1998. The veteran was hospitalized in April 1973 because of a seven-month history of numbness in the hands and legs. He underwent a skin and nail biopsy at that time. Based on the examination and testing, the diagnoses were peripheral neuropathy secondary to arsenic, mild hypertension, slight obesity and G6PD deficiency. The examiner reported that no source for the arsenic intoxication was found despite the very accurate investigation performed. The veteran suspected that the intoxication had begun at a time when he worked in an ammunition plant where he handled explosives. The veteran was readmitted from September 1973 to March 1974 because of ongoing symptoms of several weeks duration. The examiner cited the previous admission for arsenic intoxication and poisoning, which resulted in peripheral neuropathy. The veteran again underwent examination and testing. The examiner assessed the veteran with a recurrence of arsenic intoxication and increasing peripheral neuropathy secondary to arsenic. Outpatient records dated in October 1991 and January 1992 show that the veteran related a history of lead exposure in 1971 while working in an ammunition plant. The remaining VA outpatient records show examination and treatment for numerous medical problems from 1991 to 1998. The diagnoses include DJD of the thoracic spine, status post lead poisoning, hypertension, diabetes mellitus, skin lesions, episodic epistaxis, anxiety, presbyopia, right shoulder tenderness, history of lead poisoning, onychauxis, adjustment disorder with mild anxiety, diabetic neuropathy, DJD of the knees, hips and back, hammertoes, callosities, pharyngitis, degenerative changes involving the feet, osteoarthritis of the right ankle, pes planus and hallux valgus. Finally, the veteran was hospitalized in November 1998 because of acute breathing problems. The assessment was that the veteran's problems were due to obstructive sleep apnea combined with an upper respiratory infection. The veteran underwent several VA medical examinations in July and August 1998. He underwent examination by a VA physician who is board certified in internal medicine. This physician certified review of the entire claims folder including his medical treatment records from the 1970's. The physician noted that the veteran worked at an arsenal in Maryland after active service until he became sick in 1975. The veteran stated that he was told he had lead poisoning at that time. He also related working as an artilleryman during active service. The physician cited the veteran's medical history as reflected in the evidence of record. The physician also conducted a complete physical examination and ordered laboratory and diagnostic studies. The physician noted that the examination was requested to determine whether or not any of the veteran's disabilities were secondary to lead poisoning. The physician noted that the veteran had been hospitalized in April 1973 for arsenic intoxication and poisoning, and that the medical records show he was assessed with recurrent arsenic intoxication and an increase in severity of his peripheral neuropathy. The physician cited to medical treatises pertaining to neurotoxic agents and lead poisoning. The physician noted that lead poisoning in adults affects merely gastrointestinal (GI), lead colic, kidneys, saturnine gout, and peripheral demyelinating neuropathy, typically producing wrist and foot drop. The physician also noted that the occupational sources in adults include spray painting, foundry work, mining, striking lead, bad burns and automotive exhaust exposure. The physician diagnosed the veteran with peripheral neuropathy, stable hypertension with medication, arthritis, degenerative type, osteoarthritis, status post exploratory laparotomy with status post repair of the jejunum and colon laceration. The physician reported that other physicians had diagnosed the veteran with DJD of the knees, hips and lower back, chronic neck pain, diabetes mellitus, hypertension and an adjustment disorder with anxiety features. The physician opined that "[a]fter extensive review of his medical records, both present and in the past, and also his C-file, there has been no GI, kidney problems that are compatible with the lead poisoning. There is a peripheral neuropathy that was found to be of arsenic poisoning in origin." This physician did not relate any of the veteran's current disabilities to lead poisoning or any other incident or event of active service. On VA eye examination the diagnoses were hyperopia, presbyopia, small angle exotropia, and diabetes mellitus without diabetic retinopathy. This physician did not relate any of these disabilities to lead poisoning or any other incident or event of active service. On VA mental disorders examination the physician noted that the claims folder and the veteran's medical records were not available and the findings were based on the veteran's presentation and statements. The veteran reported that he was first treated for lead poisoning-related medical problems in 1975. He stated that he has been unable to identify any source of lead exposure other than working at an artillery training site during active service. The veteran complained of problems recalling events and remembering things that happened a week earlier. The physician performed a mental status examination and administered psychological tests. The physician stated that overall the veteran is functioning within the dull normal range of general intelligence. The veteran demonstrated a focal area of weakness in the area of visual memory suggesting right hemisphere cortical dysfunction. The diagnosis was cognitive disorder, not otherwise specified. The physician stated that the examination disclosed positive findings of possible right hemisphere dysfunction based on decreased grip of the non-dominant hand and weakness of visual memory. The physician opined that "[I]t would not appear to be likely that lead poisoning would result in such lateralized or focal findings. It would appear more likely that toxic poisoning would result in generalized cognitive impairments. While residuals of impairment would be possible post- recovery, this appears less likely to have occurred. A vascular etiology of the present findings would appear more likely for this veteran in light of the information provided." On VA peripheral nerves examination the veteran reported he was exposed to lead, including paint and ammunition, during active service. The veteran reported that he was first diagnosed and treated for lead poisoning in 1975. The examiner conducted a physical examination and the impression was peripheral neuropathy of the lower extremities. The examiner stated that the veteran has longstanding diabetes mellitus which could affect the peripheral nerves. The examiner also stated that the history of lead exposure resulting in weakness almost 20 years later is not well documented. The examiner noted that a request would be made for the veteran's old medical records. In an addendum, the examiner stated that the veteran's old medical records were obtained and reviewed. There was no record showing the veteran was admitted for lead poisoning, but they showed that he was admitted twice in 1973 for arsenic poisoning, which resulted in peripheral neuropathy. Based on all the information, the examiner opined that "the neuropathy residual seen at C&P examination is most likely as not secondary to the severe arsenic poisoning (two episode) in 1973." Criteria Pursuant to 38 U.S.C.A. § 5107(a), a person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The United States Court of Appeals for Veterans Claims (Court) has held that a well-grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of § [5107(a)]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The Court has also held that although a claim need not be conclusive, the statute provides that it must be accompanied by evidence that justifies a "belief by a fair and impartial individual" that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992). The Court has held that "where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is 'plausible' or 'possible' is required." Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993) (citing Murphy, at 81). The Court has held that a well-grounded claim requires competent evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). See Epps v. Brown, 126 F.3d. 1464, 1468 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). In order to establish service connection for a claimed disability the facts must demonstrate that a disease or injury resulting in current disability was incurred in active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Where there is a chronic disease shown as such in service or within the presumptive period under § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (1999). This rule does not mean that any manifestation in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt doctrine in resolving each such issue shall be given to the veteran. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Analysis Section 5107 of Title 38, United States Code unequivocally places an initial burden upon the veteran to produce evidence that his claim is well grounded; that is, that his claim is plausible. Grivois v. Brown, 6 Vet. App. 136, 139 (1994); Grottveit v. Brown, 5 Vet. App. 91, 92 (1993). Because the veteran has failed to meet this burden, the Board finds that his claim of entitlement to service connection for the multiple disorders at issue as secondary to lead poisoning must be denied as not well grounded. The three requirements for a well grounded claim: (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and, (3) medical evidence of a nexus between the claimed inservice injury or disease and a current disability. See Caluza, supra. The veteran contends that exposure to artillery, fluids used to clean the weapons, and exposure to paint while in the service caused the claimed disabilities. The service medical records are missing and the NPRC has determined that the veteran's records could not be located and may have been destroyed by a fire at that facility in 1973. Where the appellant's service medical records were lost or destroyed, the Board's obligation to explain its findings and conclusions and to consider carefully the benefit-of-the- doubt rule is heightened. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). In such cases where service records have been lost or destroyed, the Board is under a duty to advise the appellant of alternative forms of evidence that can be developed to substantiate the claim. Layno v. Brown, 6 Vet. App. 465, 469 (1994); Dixon v. Derwinski, 3 Vet. App. 261, 263 (1992). The NPRC also determined that there were no available records from the Office of the Surgeon General. The NPRC notified the RO that additional information was needed in order to conduct an organizational search for treatment records from the veteran. The RO requested the veteran by letter to provide specific information as to when and through which organization he received treatment for lead poisoning during active service. The veteran responded in January 1994 that he "received no treatment for lead poisoning in service. I first learned I had lead poisoning when I went to the VA hospital at Memphis in 1972." The RO forwarded NA Form 13055 to the veteran in June 1997 in order to obtain information regarding exposure to lead poisoning during service. The veteran responded later that month, indicating that treatment during active service was unknown. In fact, in connection with his November 1983 application for nonservice-connected disability pension benefits, the veteran reported that he was unemployed secondary to lead poisoning incurred on August 8, 1972. The veteran reported having received no treatment for lead poisoning during service. In his August 1993 application the veteran alleged that he incurred multiple disabilities as a result of lead poisoning during active service, but could not remember having received treatment for lead poisoning during service. The Board notes that during several post-service VA compensation examinations, the veteran reported that he was first diagnosed and treated for lead poisoning in or about 1975. The Board also notes that the evidence of record shows that the veteran was first examined and treated for multiple peripheral neuropathy during private hospitalization from April 1972 to September 1972. Although the VA neurological evaluation in September 1993 includes a history of lead poisoning in 1955, this was a history as related by the veteran and it is not substantiated by the veteran's other statements or by the remaining evidence of record. In fact, the veteran did not relate having been diagnosed or treated for lead poisoning during service in 1955, but only theorized that he incurred lead poisoning during active service. The Board finds that the veteran was not diagnosed or treated for lead poisoning during active service. In addition, the post-service medical evidence does not show a diagnosis of any of the claimed disabilities during the initial post- service year. The evidence shows that the veteran was hospitalized in April 1973 at a VA facility because of a seven-month history of numbness in the hands and legs. Based on the examination and testing, the diagnoses included peripheral neuropathy secondary to arsenic poisoning. The examiner reported that no source for the arsenic intoxication was found despite the very accurate investigation performed. The veteran suspected that the intoxication began at a time when he worked in an ammunition plant after active service where he handled explosives. On readmission from September 1973 to March 1974 because of ongoing symptoms, the examiner cited the previous admission for arsenic intoxication and poisoning, which resulted in peripheral neuropathy. The October 1983 statement from the veteran's treating physician certifies that the veteran had been receiving treatment for DDD, diabetes, angina pectoris and hypertension for many years. The examiner also noted that the veteran had anxiety. However, this examiner did not relate any of these post-service disabilities to active service. This physician also does not state that he treated the veteran for these conditions during the initial post-service year. The post-service medical evidence from 1991 to 1998 establishes medical diagnoses of high blood pressure, diabetes mellitus and neuropathy of the extremities, DDD, spondylosis of the lumbar spine and sclerosis, anxiety disorder, status post stab wound to the abdomen, CAD, DJD of the thoracic spine, hypertension, skin lesions, episodic epistaxis, hyperopia, presbyopia, small angle exotropia, right shoulder tenderness, onychauxis, adjustment disorder with mild anxiety, diabetic neuropathy, DJD of the knees, hips and back, hammertoes, callosities, pharyngitis, degenerative changes involving the feet, osteoarthritis of the right ankle, pes planus and hallux valgus, probable mild ocular hypertension, obstructive sleep apnea combined with an upper respiratory infection, peripheral neuropathy and a cognitive disorder, not otherwise specified. Although the veteran has presented medical evidence showing current medical diagnoses of most of the claimed disabilities, he has not presented or identified competent and probative medical evidence relating these post-service disabilities to lead poisoning during active service or any other incident or event of active service. The veteran underwent several VA medical examinations in July and August 1998. The VA physician, who is board certified in internal medicine, certified review of the entire claims folder including the veteran's medical treatment records from the 1970's. This physician cited the veteran's medical history as reflected in the evidence of record. This physician also noted that the examination was requested to determine whether or not any of the veteran's disabilities were secondary to lead poisoning. This physician cited the fact that the veteran had been hospitalized in April 1973 for arsenic intoxication and poisoning, and that the medical records show the veteran was assessed with recurrent arsenic intoxication. The physician opined that "[a]fter extensive review of his medical records, both present and in the past, and also his C-file, there has been no GI, kidney problems that are compatible with the lead poisoning. There is a peripheral neuropathy that was found to be of arsenic poisoning in origin." This physician did not relate any of the veteran's current disabilities to lead poisoning or any other incident or event of active service. The physician who performed the VA mental disorders examination noted that the claims folder and the veteran's medical records were not available and the findings were based on the veteran's presentation and statements. Despite the veteran's statement that he had been unable to identify any source of lead exposure other than working at an artillery training site during active service, the physician did not relate his diagnosis of cognitive disorder, not otherwise specified, to in-service lead poisoning. In fact, the physician opined that "[I]t would not appear to be likely that lead poisoning would result in such lateralized or focal findings. It would appear more likely that toxic poisoning would result in generalized cognitive impairments. While residuals of impairment would be possible post-recovery, this appears less likely to have occurred. A vascular etiology of the present findings would appear more likely for this veteran in light of the information provided." This physician also did not relate any of the veteran's current disabilities to any other incident or event of active service. Finally, the examiner who performed the VA peripheral nerves examination, noted that he did not initially have access to the claims folder or the veteran's prior medical records. The veteran reported to the examiner that he was exposed to lead, including paint and ammunition, during active service. After reviewing the veteran's old medical records, the examiner stated that the there was no record showing the veteran was admitted for lead poisoning, but they actually showed that the veteran was admitted twice in 1973 for arsenic poisoning, which resulted in peripheral neuropathy. Based on all the information, the examiner opined that "the neuropathy residual seen at C&P examination is most likely as not secondary to the severe arsenic poisoning (two episode) in 1973." This examiner excludes the possibility that the veteran's peripheral neuropathy is even secondary to lead poisoning. This examiner did not relate any of the veteran's current disabilities to any other incident or event of active service. The only medical evidence of record that attributes, in part, the veteran's peripheral neuropathy to lead poisoning is the September 1993 VA neurological evaluation report. This diagnosis has no probative value in establishing a well- grounded claim. The diagnosis is based on the inaccurate factual premise of lead poisoning in 1955, which was a history provided by the veteran. The Court has held that the Board is justified in rejecting a physician's opinion, which relies on a medical history from the veteran that conflicts with the service medical records. See Owens v. Brown, 7 Vet. App. 429 (1995); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (Court also held that an opinion based on an inaccurate factual premise has no probative value). In addition, the diagnosis was unenhanced by any medical comment such as providing a specific nexus between in-service lead poisoning and the post-service development of peripheral neuropathy. Rather, the physician's diagnosis was peripheral neuropathy due to either diabetes or lead poisoning. The physician provided no clinical data or other rationale in support of the diagnosis and its probative value is dependent upon the veteran's unsupported history that he had been diagnosed with lead poisoning during service. The diagnosis "sits by itself, unsupported and unexplained," and the Board considers it to be purely speculative in nature, and not sufficient to satisfy the medical nexus requirement for a well-grounded claim. See Bloom v. West, 12 Vet. App. 185, 187 (1999); see also Dixon v. Derwinski, 3 Vet. App. 261 (1992); Tirpak v. Derwinski, 2 Vet. App. 609 (1992). Consequently, the Board finds that this diagnosis does not constitute medical evidence of a relationship between in- service lead poisoning and the post-service development of peripheral neuropathy. Finally, the veteran has not submitted or identified competent medical evidence showing a current medical diagnosis of a bilateral hearing loss disability or medical diagnosis that is manifested by impaired kidney and bowel function. For the purpose of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1999). This regulation was promulgated to establish when a hearing "disability" is present within the meaning of 38 U.S.C.A. § 1110, and operates to establish whether measured hearing loss is a disability for which compensation may be paid. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). The September 1993 audiological evaluation findings do not establish that the veteran has a current hearing loss disability in accordance with 38 C.F.R. § 3.385. In fact, the VA audiologist concluded that the veteran's bilateral hearing acuity was essentially normal. The evidence of record also does not include a current medical diagnosis of a kidney disorder or a GI disorder that results in bowel dysfunction. The evidence does show a current diagnosis of status post exploratory laparotomy with status post repair of the jejunum and colon laceration, but the evidence shows that this was secondary to a November 1979 stab wound, for which he was treated at VA. The veteran has not provided or identified medical diagnoses of the claimed disabilities or medical evidence relating impaired kidney and bowel function to any incident or event of active service. The determinant issue in this case is whether any of the veteran's current disabilities is attributable to in-service lead poisoning. This is a question of medical etiology; therefore, competent medical evidence is required to well ground the claim. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993) (citing Murphy, at 81). The only evidence relating the current disabilities to in-service lead exposure consists of statements from the veteran and his in-service comrade. The evidence does not establish that either person possesses a recognized degree of medical knowledge; therefore, their opinions as to medical diagnoses and/or causation are not competent. While a lay person is competent to provide evidence on the occurrence of observable symptoms during and following service, such a lay person is not competent to make a medical diagnosis or render a medical opinion which relates a medical disorder to a specific cause. Espiritu v. Derwinski, 2 Vet. App. 492, 494-495 (1992). Neither is the Board competent to supplement the record with its own unsubstantiated medical conclusions as to whether the veteran's current disability is related to a disease or injury incurred during service. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Absent evidence of a link between the current disabilities and the claimed in-service injury, the claim is not well grounded. Pursuant to 38 U.S.C.A. § 5103(a), if VA is placed on notice of the possible existence of information that would render the claim plausible, and therefore well grounded, VA has the duty to advise the veteran of the necessity to obtain the information. McKnight v. Gober, 131 F.3d 1483, 1484-1485 (Fed. Cir. 1997); Robinette v. Brown, 8 Vet. App. 69, 80 (1995). In this case, the Board finds that the duty to inform does not attach because the veteran has not identified available evidence that would well-ground his claim, i.e., provide a nexus between a current disability and service. The Board finds that the RO has advised the veteran of the evidence necessary to establish a well grounded claim, and the veteran has not indicated the existence of any evidence that has not already been obtained that would well ground his claim. McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Brown, 9 Vet. App. 341, 344 (1996), aff'd sub nom. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Because there is no competent medical evidence of either a current disability or a nexus between the veteran's current disabilities and service, the Board finds that his claim of entitlement to service connection must be denied as not well grounded. The Board views its foregoing discussion as sufficient to inform the veteran of the elements necessary to complete his application to reopen this claim. See Graves v. Brown, 8 Vet. App. 522 (1996); Robinette v. Brown, 8 Vet. App. 69, 77-78 (1995); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). As the veteran's claim for service connection for multiple disorder claimed as secondary to lead poisoning is not well grounded, the doctrine of reasonable doubt has no application to his claim. ORDER The veteran, not having submitted a well grounded claim of entitlement to service connection for diabetes mellitus, angina, degenerative disc disease, hypertension, bilateral visual impairment, paralysis of the hands and feet extending to the knees, impaired memory, a nervous disorder, impaired kidney and bowel function, and bilateral defective hearing claimed as secondary to lead poisoning, the appeal is denied. RONALD R. BOSCH Member, Board of Veterans' Appeals