Citation Nr: 0000969 Decision Date: 01/12/00 Archive Date: 01/27/00 DOCKET NO. 98-05 067A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an increased evaluation for an anxiety state with migraine headaches, currently rated as 50 percent disabling. 2. Entitlement to service connection for a heart disability as secondary to a service connected anxiety state with migraine headaches. 3. Entitlement to service connection for a stroke, as secondary to an anxiety state with migraine headaches. 4. Entitlement to service connection for asbestosis. 5. Entitlement to service connection for a suprasellar teratoma. 6. Entitlement to a total disability evaluation for compensation purposes on the basis of individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARINGS ON APPEAL Appellant and Spouse ATTORNEY FOR THE BOARD D. Odlum, Associate Counsel INTRODUCTION The veteran had active military service from May 1974 to May 1980. This matter is before the Board of Veterans' Appeals (Board) on appeal from rating decisions from the Montgomery, Alabama Department of Veterans Affairs (VA) Regional Office (RO). In August 1980, the RO granted service connection for anxiety with migraine headaches, assigning a 30 percent rating. In October 1990, the RO increased the evaluation for an anxiety state with migraine headaches to 50 percent, effective from April 13, 1990. In November 1998, the veteran submitted a statement claiming that he was entitled to an earlier effective date for the 50 percent evaluation, contending that his anxiety state should have warranted a 50 percent rating back to April 1, 1989. As this issue has been neither procedurally developed nor certified for appellate review, the Board is referring it to the RO for initial consideration and appropriate action. Godfrey v. Brown, 7 Vet. App. 398 (1995). The Board also notes that the veteran, in November 1996, and again in April 1998, raised a claim of service connection for a seizure disorder. As this issue has been neither procedurally developed nor certified for appellate review, the Board is referring it to the RO for initial consideration and appropriate action. Id. In February 1997, the RO denied, in pertinent part, service connection for hearing loss. The veteran submitted a Notice of Disagreement (NOD) in which he specifically disagreed with certain portions of the February 1997 rating decision. With regard to hearing loss, the veteran said, "Forget about my claim for hearing loss." The Board concludes that the veteran therefore effectively withdrew his claim of service connection for hearing loss. See 38 C.F.R. § 20.204 (1999). In April 1998, the veteran re-asserted his claim of service connection for hearing loss. As this issue has been neither procedurally developed nor certified for appellate review, the Board is referring it to the RO for initial consideration and appropriate action. Godfrey, supra. In a letter to Senator John McCain, the veteran indicated that he suffered additional disability as a result of VA treatment in December 1996. In particular, he referred to treatment at the Tuscaloosa VA Medical Center (VAMC). In November 1998, the veteran submitted another letter in which he indicated his intent to file a claim based on additional disability resulting from VA treatment. He again referred specifically to treatment received at the Tuscaloosa VAMC in December 1996. The Board finds that an inferred claim of entitlement to compensation pursuant to the provisions of 38 U.S.C.A. § 1151 (West 1991 & Supp. 1999) has been raised. As this issue has been neither procedurally developed nor certified for appellate review, the Board is referring it to the RO for initial consideration and appropriate action. Godfrey, supra. With respect to the issue of entitlement to a TDIU, the Board notes that the veteran first indicated an inability to work in November 1996 (claiming that his anxiety state warranted a 100 percent rating), and again in January 1997, contending that he was not able to work due to his service connected disability. In January 1998, the veteran submitted a statement specifically claiming entitlement to a TDIU. In May 1998 the RO denied entitlement to a TDIU. In November 1998 the veteran submitted a statement claiming that clear and unmistakable error (CUE) had been committed in the May 1998 rating decision denying a TDIU. The veteran also submitted an NOD dated earlier in November 1998 (received by the RO in December 1998) in which he specifically expressed his disagreement with the May 1998 rating decision denying entitlement to a TDIU. In March 1999 the RO found that CUE had not been committed in the May 1998 rating decision. In April 1999 the veteran submitted a statement again contending that he was entitled to TDIU and indicating disagreement with the May 1998 and March 1999 rating decisions. The Board is of the opinion that the issue of CUE has not been successfully raised before the Board. The United States Court of Appeals for Veterans Claims (Court) has held that CUE requires more than a disagreement on how the facts are weighed or evaluated; the appellant must show that the correct facts, as they were known at the time, were not before the adjudicator or that pertinent regulatory or statutory provisions were incorrectly applied. See Russell v. Principi, 3 Vet. App. 310, 313 (1992). In order for a valid CUE claim to be raised, the veteran must allege with some specificity what the alleged error is, and, unless it is patently clear and unmistakable, the veteran must provide persuasive reasons as to why the result would have been manifestly different but for the alleged error. Bielby v. Brown, 7 Vet. App. 260, 269 (1994); Fugo v. Brown, 6 Vet. App. 40, 44 (1993); See Eddy v. Brown, 9 Vet. App. 52; 57 (1996). In alleging CUE, the veteran has merely expressed disagreement with the outcome of the May 1998 rating decision, i.e., the denial of entitlement to TDIU. He has not alleged with any specificity what error of law or fact was present that lead to CUE in the May 1998 rating decision. The veteran simply averred that there was CUE. It is an "unassailable proposition that merely to aver that there was CUE in a case is not sufficient to raise the issue." Bielby, supra; Fugo at 43. In fact, the substance of the November 1998 statement appears to more accurately resemble a Notice of Disagreement (NOD) with the May 1998 rating decision. This is supported by the veteran's November 1998 submission of a specific NOD with the May 1998 rating decision. Subsequent statements submitted by the veteran have indicated his disagreement with the May 1998 rating decision without any specific alleged error of law or fact. Thus, as the veteran submitted a timely NOD with the May 1998 rating decision, the Board concludes that the May 1998 rating decision denying TDIU never became final. Previous determinations which are final and binding will be accepted as correct in the absence of CUE. 38 C.F.R. § 3.105(a) (1999). It has been recognized that a claimant seeking to show that CUE has been committed has a much heavier burden than that placed upon a claimant who attempts to establish his prospective entitlement to benefits. Akins v. Derwinski, 1 Vet. App. 228, 231 (1991). The record shows that the May 1998 rating decision did not become final as the veteran file a timely notice of disagreement with the decision. It also shows that the veteran has continued to express disagreement with the May 1998 rating decision without alleging a specific error of law or fact. The Board therefore concludes that the veteran should not be subject to the burden of having to show CUE in the May 1998 rating decision in order to obtain a TDIU because the May 1998 rating decision never became final. See 38 C.F.R. § 3.105(a), Akins, supra. In light of the above, it is concluded that the issue of CUE has not been properly raised and is not before the Board. As the veteran has submitted a timely NOD with respect to the May 1998 denial of entitlement to a TDIU, the Board concludes that the proper issue before it at this time is entitlement to a TDIU. This issue shall be addressed in the remand portion of the decision. The issue of entitlement to service connection for a stroke as secondary to an anxiety state with migraine headaches is also addressed in the remand portion of this decision. Finally, the Board notes that during the August 1999 hearing the veteran contended that he has current lung and sinus problems that are secondary to neurotoxin poisoning in the service. He also contended that he had suffered with these problems in the service and continuously since his discharge from service. Transcript, p. 9. As this issue has been neither procedurally developed nor certified for appellate review, the Board is referring it to the RO for initial consideration and appropriate action. Godfrey, supra. The Board notes that additional evidence has been submitted to the Board, some of which was not initially considered by the RO; however, the veteran submitted a statement with this evidence waiving initial RO consideration of such evidence. 38 C.F.R. § 20.1304(c) (1999). FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the issues of entitlement to an increased evaluation for an anxiety state with migraine headaches and service connection for a heart disability have been obtained. 2. The probative medical evidence shows that the veteran's anxiety state with migraine headaches results in total occupational and social impairment. 3. The probative medical evidence shows that the veteran's heart disability is causally related to a service-connected anxiety state disability. 4. The claims of entitlement to service connection for asbestosis and a suprasellar teratoma are not supported by cognizable evidence showing that the claims are plausible or capable of substantiation. CONCLUSIONS OF LAW 1. The criteria for a 100 percent evaluation for an anxiety state with an additional separate 50 percent rating for migraine headaches have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3, 4.25, 4.124a, 4.130, Diagnostic Codes 8100 and 9411 (1999). 2. The veteran's heart disability is proximately due to or the result of a service-connected anxiety state with migraine headaches disability. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1999). 3. The claims of entitlement to service connection for asbestosis and a suprasellar teratoma are not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Entitlement to an Increased Rating for an Anxiety State with Migraine Headaches Factual Background The pertinent evidence of record shows that the veteran was being treated for anxiety, depression, and migraine headaches from February 1995 through October 1995. A progress note from April 1995 specifically noted that he had recently had a two week history of multiple headaches. In a VA progress note from November 1995, the veteran was noted as reporting migraine headaches four times per month. On follow-up in January 1996, he was still complaining of migraine headaches. A progress note from February 1996 indicated that he was being treated for a migraine/nerve disorder. A progress note from February 1996 again documented complaints of four migraines per month. Progress notes from Dr. C.P.M. from March 1996 indicated that the veteran was usually having four migraine headaches per month. A progress note from May 1996 noted the occurrence of five migraine headaches that month. Progress notes through November 1996 show treatment of migraines and anxiety. In November 1996, the veteran submitted, in pertinent part, a claim for an increased evaluation of his anxiety state with migraine headaches. In December 1996 the veteran was admitted to the Tuscaloosa VAMC. The discharge report noted that there was a "different concept of information" showing a lot of discrepancy from documentation. Multiple instances of threatening behavior were noted as being documented, including threats towards the staff, other patients, and a history of violent behavior towards his wife; however, the veteran denied that such instances occurred, including violence towards his wife. It was noted that his wife had denied such violence during his admission. The admitting diagnosis, in pertinent part, was generalized anxiety disorder. He was treated and, as a precautionary measure, transferred to "PICU." The discharge diagnosis was, in pertinent part, generalized anxiety disorder, with a Global Assessment of Functioning (GAF) level of 55. In a statement written to Senator John McCain, the veteran gave his account of the December 1996 VAMC admission, contending that he had not threatened to harm anyone, including his wife. In January 1997, Dr. J.P.D.M. reported that he had first seen the veteran in January 1996. He noted that he had initially found the veteran to have attention deficit hyperactivity disorder (ADHD), residual in nature. He further noted that the veteran's developmental history, the progression of his signs and symptoms, and the episodic nature of his psychological problems made it likely that he had probable residual ADHD and Bipolar Disorder. His clinical diagnoses were Bipolar Disorder, mixed type, with anxiety and depression, and prominent ADHD. He also concluded that there was a personality style characterized by an aggressive posturing. In February 1997, Dr. J.P.D.M. indicated that he was continuing to see the veteran and that his clinical diagnoses were residual ADHD, affective disorder (not otherwise specified (NOS)), mixed personality disorder, and anxiety disorder NOS. He concluded that there had been a progressive deterioration in the veteran's ability to function competently in his current position. He also noted that he was demonstrating a marked lability of affects and an inability to perceive himself as others do. He concluded that this condition would continue for more than a year and render him unable to provide useful and efficient service. He re-asserted this in October 1997. February 1997 progress notes from Dr. C.P.M. note that the veteran was continuing to suffer from migraines at about the same frequency. In March 1997 it was noted that he had suffered from six or seven headaches that month. Examination revealed positive nausea and positive photophobia. In May 1998 Dr. J.P.D.M. concluded that the veteran was disabled and unable to work. It was concluded that the clinical criteria, in pertinent part, for bipolar disorder, ADHD, episodic alcohol abuse, mixed personality disorder, and migraine headaches had been met. Dr. J.P.D.M. assigned a GAF of 35 which he noted as being characterized by impairment in the veteran's ability to judge the intent of others, inability to work, chronic irritability with his wife, staying in bed while depressed for the majority of the day, having few friends outside his home, and being unrealistic about his ability to represent himself in multiple social situations. Dr. J.P.D.M. further noted that the veteran was suffering from chronic irritability, absent libido, difficulty with sleep, weight gain, and increased isolation, not having a week without serious disabling symptoms. He concluded that the veteran was ill and needed intensive supervision of his care. His lack of judgment, impulsivity, and irritability was not his choice but rather behavioral and affective expressions of his psychiatric illnesses. In May 1998 a local hearing was conducted. It was asserted that the anxiety and migraine conditions should be rated separately. Tr., p. 2. Regarding his psychiatric disability, the veteran testified that he did not interact well with other people and had a short temper. He also reported being a "rapid cycler" with periods of depression and mania. He stated that he did not leave the house unless he had to because of his fear of what he might do to someone if he goes somewhere public. Tr., p. 2. He testified to having problems with his employers, stating that he "cussed 'em out" and did everything short of punching them out. Tr., p. 3. He denied going anywhere, having friends, seeing anybody, or doing anything. Id. He stated that he spent his day mostly worrying. Tr. p. 4. Regarding his headaches, the veteran testified that both the headaches and his nervous condition arose around the same time and that they were both associated. Tr., p. 5. He reported averaging about four migraines per month. Tr., p. 5. He reported that these headaches were "brutal," and that they would knock him on the floor and give him nausea, vomiting, photophobia. He testified that he had to go to the hospital when he would run out of medication as a result of having more than four headaches in a month. Tr., p. 5. He testified that it could take him from one to as long as three days to recover from a headache. Tr., p. 7. The veteran's spouse testified that the veteran had a temper and that he could become violent when he lost his temper. She reported that he had become verbally aggressive towards other people. Tr., p. 18. She testified that he had migraines quite frequently during the month. Tr., p. 19. In July 1998 the veteran underwent a VA mental disorders examination. On examination, he reported that he had considered killing others because he would not tolerate anything violent being done to him. He reported not doing anything for fun and stated that he did not want to be happy. He reported panic attacks, social isolation, and withdrawal. He felt that he was a threat to other people if they were a threat to him or his family. On examination, the veteran made no attempt to interact or relate with the examiner. Responses to questions were brief. Effective responses were blunted and he appeared to be heavily sedated. The diagnosis was dysthymic disorder exhibited by low energy, poor concentration, sleep disturbance, and a depressed mood for most of the day. A GAF of 50 was assigned. In January 1999 the Social Security Administration (SSA) determined that the veteran was disabled due to his psychiatric disabilities. In August 1999 a hearing before a travel Member of the Board was conducted. The veteran testified that he was continuously either depressed or manic, but primarily depressed. Tr., p. 3. He testified that his psychiatric disability had a very negative impact on his family. Tr., pp. 4-5. Regarding headaches, the veteran testified that he had been averaging four migraine headaches per month since 1988. Tr., p. 6. He testified to having nausea with these headaches and that they were totally incapacitating. Tr., p. 6. Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See 38 C.F.R. § 4.2 (1999); Francisco v. Brown, 7 Vet. App. 55 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings, nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20 (1999). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. The United States Court of Appeals for Veterans Claims (Court) has held that a veteran may not be compensated twice for the same symptomatology as "such a result would overcompensate the veteran for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Under the pertinent criteria for mental disorders, a 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9400 (1999). A 70 percent evaluation is provided for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Rating Schedule also provides that when evaluating the mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission shall be considered and the evaluation shall be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. The evaluation also must consider the extent of social impairment, but shall not be assigned solely on the basis of social impairment. When a single disability has been diagnosed both as a physical condition and as a mental disorder, the rating agency shall evaluate it using a diagnostic code which represents the dominant (more disabling) aspect of the condition. 38 C.F.R. § 4.126. The Rating Schedule provides compensation for migraine headaches with characteristic prostrating attacks averaging one in two months over the last several months (10 percent); with characteristic prostrating attacks occurring on average once a month over the last several months (30 percent); and with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability (50 percent). A noncompensable rating is provided for migraine headaches with less frequent attacks. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (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 appellant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Analysis Initially, the Board notes that the veteran's claim is found to be well-grounded under 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented a claim which is plausible. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of increased disability is sufficient to establish a well-grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is also satisfied that all relevant facts have been properly developed, and that no further assistance is required in order to satisfy the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). The veteran has been diagnosed with a variety of non-service connected psychological impairments, including ADHD, depression, mixed personality disorder, an affective disorder, bipolar disorder (mixed type), and bipolar disorder with anxiety and depression. He is service-connected for an anxiety state with migraine headaches. There is no probative evidence that clearly distinguishes the symptoms attributed to the veteran's service-connected anxiety state and symptoms attributed to the other psychological disorder or disorders. When it is not possible to separate the effects of the service-connected condition and the non-service-connected condition or conditions, VA regulations at 38 C.F.R. § 3.102, requiring that reasonable doubt on any issue be resolved in the veteran's favor, clearly dictate that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); 61 Fed. Reg. 52698. In light of the above, the Board shall consider all of the veteran's various symptoms in assigning a rating for the veteran's anxiety state. See Mittleider at 182. The Board concludes that the evidence demonstrates that the veteran's anxiety state has resulted in total occupational and social impairment, and therefore warrants a rating of 100 percent. 38 C.F.R. § 4.7 (1999). The record indicates that the veteran has demonstrated gross impairment in thought process and communication. This is illustrated by the apparent discrepancy between the veteran's perception of his December 1996 admission to the Tuscaloosa VAMC and the perceptions of employees who came into contact with the veteran during that time, who indicated that the veteran had threatened them with violence, contrary to the veteran's own account. Dr. J.P.D.M. concluded in February 1997 that the veteran had demonstrated (referring to the Tuscaloosa VAMC hospitalization) marked lability of affects and an inability to perceive himself as others do. The record indicates that he had cursed at fellow employees when he was working and has thought of violence towards others. He has reported not having any friends, no activities, and staying confined mostly to the house. See Transcript, p. 3 (May 4, 1998). In May 1998 Dr. J.P.D.M. concluded that the veteran was disabled and unable to work. He assigned a GAF of 35 as characterized by the veteran's impairment in his ability to judge the intent of others, inability to work, chronic irritability with his wife, staying in bed while depressed for the majority of the day, having few friends outside his home, and being unrealistic about his ability to represent himself in multiple social situations. He noted that the veteran had not been able to go a week without serious, disabling symptoms. During the July 1998 VA mental disorders examination, it was noted that the veteran had been unemployed since November 1996. He denied having social contact and stated that he rarely ventured from his house. He reported suffering from panic attacks, and stated that he had considered killing people. The diagnosis was dysthymic disorder as manifested by low energy, poor concentration, sleep disturbance, and depressed mood for most of the day. A GAF of 50 was assigned. The Board notes that there is some question as to whether the veteran's psychiatric disability adequately satisfies the criteria for a 100 percent rating under Diagnostic Code 9400 or would be more appropriately rated under the criteria for a 70 percent disability rating. However, based on the veteran's history of psychological symptoms, and the observations of Dr. J.P.D.M., particularly those findings concerning his impaired perception and judgment, and history documenting his potential danger towards others, the Board concludes that the veteran's psychiatric disability picture more nearly approximates the criteria required for a 100 percent rating than that for a 70 percent rating. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9400. The record shows that the migraine headaches have been rated as part of the service-connected anxiety state under 38 C.F.R. § 4.130, Diagnostic Code 9400. However, there is no indication that Diagnostic Code 9400 includes migraine headaches as a symptom within its rating criteria. As was stated above, when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban, supra. Therefore, the Board concludes that the veteran's migraine headaches should be rated under the diagnostic code for migraine headaches rather than rated under the criteria for mental disorders because the criteria for mental disorders clearly does not contemplate migraine headaches. See 38 C.F.R. §§ 4.124a and 4,130, Diagnostic Codes 8100 and 9400. A 30 percent rating for migraine headaches requires characteristic prostrating attacks occurring once a month on average over the last several months, and the maximum 50 percent rating requires very frequent, completely prostrating, and prolonged attacks, productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. Pertinent medical records have documented that the veteran has been receiving treatment for migraine headaches which have been noted as occurring usually at a rate of four times per month and sometimes more. Photophobia and nausea associated with these migraines have been documented. He indicated at both hearings that the migraine episodes were totally incapacitating. Transcript, p. 6 (May 4, 1998); Transcript, p. 6 (August 13, 1999). At the May 1998 hearing, the veteran testified that it would take him anywhere from 24 hours to three days to recover from a migraine headache. Tr., p. 7. The Board concludes that this evidence demonstrates that the veteran's migraine headaches more nearly approximate the disability criteria required for the maximum 50 percent rating, as the record has indicated that he has experienced significant migraine attacks four times a month on average for the last several years. 38 C.F.R. §§ 4.7 and 4.124a, Diagnostic Code 8100 (1999). Service Connection Claims Factual Background Pertinent service medical records show that the veteran's April 1974 entrance examination documented the nose, sinuses, mouth and throat, lungs and chest, heart, and neurological condition as being normal. He reported a history of ear, nose, and throat trouble, but denied chronic or frequent colds, sinusitis, a head injury, asthma, shortness of breath, pain or pressure in the chest, a chronic cough, palpitation or pounding heart, heart trouble, and high or low blood pressure. A chest x-ray was found to be normal. In May 1975 the veteran was seen for nasal decongestion. Examination revealed an inflamed throat, and the diagnosis was a flu syndrome. He was seen with a history of a month long cold in June 1976. Examination revealed chest rales and an obstructed nasal airway. The diagnosis was allergic rhinitis. In March 1978 the veteran underwent a brain scan which was found to reveal no abnormalities and was concluded to be a normal study. In July 1979 the veteran was treated for a viral upper respiratory infection. On follow-up a chest x-ray was interpreted as showing right middle lobe pneumonia. Notes from August 1979 show treatment of pneumonia. A chest x-ray taken in August 1979 showed right middle lobe pneumonia. The remaining fields were clear revealing only residuals of old granulomatous disease. An August 1979 follow-up x-ray was found to reveal considerable clearing of the right middle lobe pneumonia with some remaining residuals, but no evidence of new disease. X-rays of the chest in September 1979 were interpreted as showing that the pneumonia had, for all practical purposes, cleared, and that the residual described on the August 1979 x-ray had also improved. Progress notes from September 1979 indicate that the veteran was feeling "OK" and that he was doing well. The diagnosis was resolved right middle lobe pneumonia. A chest x-ray performed on separation examination in January 1980 was interpreted as showing no abnormalities. Following his discharge from service, the veteran underwent a VA examination in July 1980. On neurological examination, motor power was noted as being normal, reflexes were active and equal, and there were no pathological toe or finger signs. Posterior column and cerebellar systems were intact. Gait and station were unremarkable. On VA examination in June 1987, neurological examination was found to be entirely normal without exception. In April 1988 the veteran was admitted to the Little Rock VAMC with a history of migraine headaches. It was noted that he had a work-up in 1987 for his headaches which he reported as showing a normal computerized tomography (CT) scan and EEG. An EEG performed on admission revealed midline rhythms which were minimal and nonspecific. In August 1988 the veteran underwent a VA examination in which he was examined for migraine headaches. It was noted that the veteran had undergone extensive work-ups in the past at the VA, including CT scans and electroencephalograms (EEG), both of which were noted as being normal. Neurological and motor examinations were indicated as being normal. In June 1989 a CT scan of the head was found to reveal no evidence of brain abnormalities. It was noted that the abnormality in the posterior suprasellar cistern was most likely fatty in nature with an area of calcification beside it, possibly of a teratoma, a lipoma, a dorsum sella, or an epidermoid cyst. A progress note from September 1989 noted that the veteran had been seen for intractable migraines. It was also noted that a CT scan and a magnetic resonance imaging scan (MRI) from August 1989 had revealed an "incidental teratoma." The impression was intractable migraines and a suprasellar teratoma. A progress note from October 1989 noted that the suprasellar teratoma was asymptomatic. In February 1990 the veteran was seen at the Little Rock VAMC with a history of headaches and a more recent history of a suprasellar calcification. Neurological examination was found to be normal. A CT scan of the head from February 1990 was interpreted as revealing changes consistent with a suprasellar teratoma without enhancement or interval change. Neuropsychological testing performed in April 1990 revealed very subtle and focal right hemisphere dysfunctions on motor testing, but with above average memory and intellectual functioning in general; and an abnormal "MMPI" profile consistent with a somatization disorder. In August 1990 the veteran was seen with a reported history of an episode of left-sided weakness and numbness three years prior with no subsequent episodes but that he had noticed some subtle problems in using his left hand. A four vessel cerebral angiography was found to be normal, and formal visual field testing was also found to be normal. Neurological examination was normal. Chest x-rays taken in August 1990 revealed no active parenchymal lung pathology and a ununited fracture of the left clavicle. In September 1990 the veteran underwent a VA neurological examination. Regarding the teratoma, the veteran reported that the neurosurgeon who had seen him did not feel that the "growth" was related to his headaches and that removing the growth would not prevent the headaches from continuing. Neurological examination revealed good grip strength bilaterally, no ataxia, normal gait, and symmetrical reflexes with no Babinski present. A CT scan of the head in November 1990 revealed a calcific density, unchanged from the previous February 1990 examination. A progress note from August 1991 noted, in pertinent part, that the suprasellar mass was stable. In April 1995, an MRI of the brain was found to reveal a lobulated mass located in the suprasellar cistern just posterior to the stalk of the pituitary gland, demonstrating signal characteristics identical to fat. Differential diagnoses of lipoma, epidermoid, or teratoma were noted. It was also noted that the mass was quite small. In October 1995 the veteran underwent a medical review and toxicology consultation for asbestos. A reported history of asbestos exposure was noted. No medical records were available for evaluation. The occupational history was noted as being a drywall/sheet rock worker since 1966 and that he had been employed with the Department of Defense since 1986. The veteran contended that he was exposed to asbestos during work which concluded painting and drywall work. Specific pulmonary problems were noted as including bronchitis, coughing, shortness of breath on exertion, chest pain, bilateral chest injury, and pneumonia. A chest x-ray was found to reveal parenchymal abnormalities consistent with pneumoconiosis. The bronchovascular markings were slightly increased and the pleural examination was remarkable for right apical pleural thickening. The examiner concluded that the veteran's occupational exposure history, latency, and chest x-ray findings satisfied the criteria for probable asbestosis. He also concluded that the veteran's history of cigarette smoking was an important contributing factor to his pulmonary disease. Clinical correlation was recommended. Progress notes of Dr. C.P.M. from February and March 1996 show treatment of migraine headaches. In March 1996 it was specifically noted that the veteran had a suprasellar cystic lesion which had not been felt to have any bearing on his migraines. Progress notes from Dr. C.P.M. through October 1996 show treatment of primarily migraine headaches with no documentation of complaints of or treatment for asbestosis, a suprasellar teratoma, or other neurological symptoms. In November 1996 the veteran was admitted to the Columbia Medical Center of Huntsville with a history of retrosternal chest pain. It was noted that he had multiple risk factors for coronary artery disease including smoking, a previous history of a cerebrovascular accident, and a positive family history of coronary artery disease. On examination, there was a soft systolic murmur at the left sternal border without any radiation. A Cardiolite Perfusion Study was performed during which the veteran exercised on Bruce protocol. He exercised for nine minutes and 10 seconds attaining a peak heart rate of 174 beats per minute. Following termination of the exercise, Cardiolite was injected, and imaging showed a moderate sized high grade defect in the inferior wall of the left ventricle which showed reversibility with normalization at rest. This was found to be indicative of ischemia in the right coronary artery distribution. It was concluded, in pertinent part, that the veteran had stress induced ischemia in the inferior wall in the distribution of the right coronary artery. The impression was new-onset angina. Following the Cardiolite Study, the veteran underwent a left heart cardiac catheterization, selective coronary angiography, and left ventriculography. From these studies it was concluded that there was no hemodynamically significant coronary artery disease, normal left ventricular end diastolic pressure, and normal left ventricular systolic function and no mitral regurgitation. In November 1996 the veteran raised a claim of, in pertinent part, service connection for asbestosis, claiming that it was aggravated in the service by pneumonia. In December 1996, the veteran raised a claim of service connection for a heart disability as being secondary to his service connected anxiety disability. In December 1996, the RO received a treatise which generally discussed, in pertinent part, angina pectoris. The treatise indicated that angina can be caused by emotion such as extreme fear, anger, grief, or frustration. In December 1996 the veteran was seen at the Huntsville VAMC with complaints of chest pain. It was noted that previous studies had been normal and that the pain was usually anxiety related. The diagnosis, in pertinent part, was chest pain and a possible panic attack, but that a spasm was a possibility. In January 1997 the RO received two treatises, one a series of excerpts from the Merck Manual, and the other a treatise regarding industrial hazards. The excerpts from the Merck Manual included discussions of pneumonia, pleural disorders, and neurologic disorders. Neither treatise specifically addressed asbestosis or aggravation of asbestosis. The veteran again contended in a statement submitted with the treatises that he had asbestosis prior to entering the military and that in-service pneumonia had aggravated this condition. Progress notes from Dr. C.P.M. through September 1997 show treatment of primarily migraine headaches with no documentation of complaints of treatment for a suprasellar teratoma, or other neurological symptoms. A progress note from January 1997 showed treatment of shortness of breath, described as bronchitis, and chills. It was noted that this was the veteran's third reported history of shortness of breath. Examination revealed a non-productive cough. Progress notes from September 1997 note that he was complaining of a problem with his lungs. It was noted that he had shortness of breath only with heavy exertion and an occasional cough. No diagnosis of asbestosis was documented. Progress notes from Dr. C.P.M. from this period document complaints of chest pain. In December 1996, the veteran was requesting treatment for his angina, stating that he had chest pain whenever he was stressed. Dr. C.P.M. noted a previous negative Cardiolite Study and concluded that the veteran was basically suffering from anxiety, and that the chest pain resulted from his anxiety. In May 1998 a local hearing was conducted. During the hearing, the veteran was asked whether he had been told that his heart condition was secondary to his service connected anxiety disability. Transcript, p. 7. He replied that "[i]t is called stress induced ischemia." Tr., p. 8. He reported that he was merely sitting and not exercising when he suffered an attack; however he denied that his anxiety state had increased during that particular attack. Tr., p. 8. The veteran testified that he was diagnosed with asbestosis in February 1995 and that he was exposed to asbestos while a painter which he testified to performing from the age of 14 until he entered the military. Tr., pp. 8-9. He testified that his pre-existing asbestosis was aggravated while he was in the military, stating that he was hospitalized for pneumonia and suffered from bronchitis, obstructed airways, and flu-like symptoms. Tr., p. 9. He testified that his current residuals of this aggravation was calcification of the lungs. Tr., p. 10. He contended that his suprasellar tumor was caused by exposure to chemicals while in the service. Tr., pp. 10-11. In June 1998 a VA general medical examination was conducted. Subjective complaints were noted as including occasional chest pain, irregular heartbeats with tachycardia at times, chronic cough and expectorate, migraine headaches, and a history of a transient ischemic attack in 1987. Examination of the ears, nose, sinuses, mouth, and throat were found to be negative. The chest showed almost bronchial breathing on both sides with a lot of rales bilaterally. The cardiovascular system showed normal sounds with no murmurs but a pulse rate between 96 and 100. Neurological examination was described as being essentially negative. The veteran was noted as being extremely anxious and depressed. The diagnoses were, in pertinent part, anxiety and depression, chronic obstructive pulmonary disease (COPD), migraine headaches, a history of angina pectoris, a history of "TCI," and a history of a benign suprasellar brain tumor. Tests were ordered, and pulmonary function testing found Forced Vital Capacity (FVC) to be 4.07 liters, or 84 percent of predicted. Forced Expiratory Volume (FEV1) was 3.37 liters, or 88 percent of predicted. It was concluded that there was no obstruction or restriction. In December 1998 the veteran was seen for shortness of breath and coughing. The diagnosis was COPD and pulmonary function testing was ordered. During pulmonary testing, it was noted that the veteran smoked occasionally and had a reported history of asbestos exposure. FVC was 3.50 or 69 percent of predicted, and FEV1 was 2.92 liters or 70 percent of predicted. These tests were interpreted as revealing a mild obstructive ventilatory impairment with moderate air trapping and normal "ABG's ." On follow-up in December 1998, the test results were interpreted as showing a moderately severe impairment with air trapping. The assessment was severe emphysema with air trapping. In August 1999 a hearing before a travel Member of the Board was conducted. The veteran testified, in pertinent part, to having a stroke in 1987. Transcript, p. 7. He denied being told by any doctor that the stroke was associated with his anxiety disorder. Id. He denied receiving any current treatment for his stroke. Tr., p. 8. When asked whether it was fair to say that his stroke was secondary to his service connected psychiatric disability, the veteran testified that his stroke resulted from medication given to him for his migraine headaches. Tr., p. 12. The veteran testified to being exposed to asbestos prior to entering the service and indicated that this condition was aggravated by multiple respiratory problems incurred while in the military. He denied being exposed to asbestos while in the military. Tr., pp. 8-9. The veteran testified that his suprasellar teratoma was incurred in service, and that the reason it was not detected earlier was due to technology, or lack thereof, of the time. Tr., p. 9. He denied receiving any current treatment for the teratoma. Tr., p. 10. The veteran testified that his heart disorder resulted from neurotoxin poisoning. He contended that neurotoxin poisoning had damaged his lungs, and indicated that, as a result, he had suffered myocardial ischemia due to lack of oxygen going for the heart. Tr., p. 12. 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). Continuous service for 90 days or more during a period of war, and post-service development of a presumptive disease to a degree of 10 percent within one year from the date of termination of such service, establishes a presumption that the disease was incurred in service. 38 C.F.R. §§ 3.307, 3.309 (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). The veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b) (1999). Generally, a preexisting injury or disease will be considered to have been aggravated by active service, where there is an increase in disability during such service. Unless there is a specific finding that the increase in disability is due to the natural progress of the disease; however, aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306 (1999). In order to establish aggravation of a preexisting injury or disease, clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. This includes medical facts and principles which are to be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306 (1999). "[I]n short, a proper application of [38 U.S.C. § 1153 and 38 C.F.R. § 3.306 (a), (b)] . . . places an onerous burden on the government to rebut the presumption of service connection" and "in the case of aggravation of a preexisting condition, the government must point to a specific finding that the increase in disability was due to the natural progress[ ] of the disease". Akins v. Derwinski, 1 Vet. App. 229, 232 (1991). Service connection may also be granted for disability, which is proximately due to, or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a) (1999). When there is aggravation of a nonservice-connected condition, which is proximately due to, or the result of service-connected disease or injury, the veteran will be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). As to disorders related to asbestos exposure, the absence of symptomatology during service or for many years subsequent to separation does not preclude the eventual development of the disease. VA Adjudication Procedure Manual, M21-1, Part VI, 7.21; 38 C.F.R. § 3.303(d). The time length of exposure is not material, as individuals with relatively brief exposures of less than one month have developed asbestos-related disorders. See Department of Veterans Benefits of the Veterans Administration, Asbestos- Related Diseases, DVB Circular 21-88-8 (May 11, 1988). 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 Initially, the Board finds that the veteran's claim for service connection for a heart disability as secondary to an anxiety state with migraine headaches is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). The veteran has been diagnosed with a current disability of the heart and a physician has attributed the veteran's chest pain to his anxiety. The Board finds that all indicated development has been completed, and VA has satisfied its duty to assist the veteran. 38 U.S.C.A. § 5107(a). After carefully reviewing the record, the Board concludes that there is an approximate balance of positive and negative evidence relating to the veteran's claim for service connection of a heart disability. Therefore, applying the benefit of the doubt rule, the Board concludes that his heart disability proximately resulted from or was aggravated by his anxiety disability. As the Board noted earlier, the veteran's claim is predicated on the basis of a secondary relationship between his service-connected anxiety disability and heart disorder. The November 1996 Cardiolite Study indicated that the veteran's ischemia was induced by stress from exercise. However, subsequent studies of the heart proved to be negative for heart disease. Furthermore, the record has documented the veteran's complaints of angina/chest pain being triggered by an increase in anxiety. Most significantly, Dr. C.P.M. noted the veteran's history regarding his heart and concluded that his chest pain resulted from his anxiety. For the foregoing reasons and bases, the Board finds that the evidence is evenly balanced as to require application of the benefit of the doubt in favor of the veteran. Thus, the Board finds that service connection for a heart disability as secondary to an anxiety state with migraine headaches is warranted. Gilbert, 1 Vet. App. at 56. With respect to the claims for asbestosis and a suprasellar teratoma, 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 claims are 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 claims of entitlement to service connection for asbestosis and a suprasellar teratoma must be denied as not well grounded. The Board reiterates 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 record shows that the veteran has been diagnosed with a suprasellar tumor since his discharge from the military service. However, there is no competent medical evidence linking suprasellar teratoma to service or to any service connected disabilities. In fact, medical records have indicated that the suprasellar teratoma has been asymptomatic and not related to the veteran's migraine headaches. There is no competent medical evidence linking the suprasellar teratoma to the anxiety state with migraine headaches or to military service. With respect to asbestosis, the veteran has alleged that he was exposed to asbestos prior to service and that he aggravated this condition while in the service. He specifically has denied being exposed to asbestos while in the military. Transcript, p. 8 (August 13, 1999). While service medical records show treatment of various respiratory ailments, they do not document asbestosis nor indicate that he had this condition prior to enlisting in the service. A chest x-ray on enlistment examination in April 1974 was described as normal. Nor has the veteran presented clear and unmistakable evidence that he had asbestosis prior to service. 38 C.F.R. § 3.304(b) (1999). The veteran has reported a pre-service history of asbestos exposure, and he was found to meet the criteria for probable asbestosis in February 1995. There is a chest x-ray in the service medical records from August 1979 in which the residuals of an old granulomatous disease was revealed; however, there is no clear and unmistakable evidence (obvious and manifest) that he had asbestosis prior to entering the military service. It is not obvious and manifest that the residuals of an old granulomatous disease was a manifestation or evidence of asbestosis or even as to how "old" this disease was. Further, chest x-rays on enlistment examination in April 1974 were described as normal. Therefore, the Board concludes that the veteran has not rebutted the presumption of soundness for the purpose of establishing that asbestosis pre-existed service, even presuming pre-service exposure to asbestos. 38 C.F.R. § 3.304(b). It is not clear from the record that the veteran has been currently diagnosed with asbestosis. In February 1995, a physician concluded that the veteran satisfied the criteria for probable asbestosis. There is no other documentation in the record documenting a diagnosis of asbestosis. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Regardless, there is no competent medical evidence linking a current asbestosis disability to military service. In addition, there is no evidence that the veteran was diagnosed with any chronic disease in service or during an applicable presumption period. Nor is there medical evidence of a relationship between the veteran's alleged current asbestosis and any alleged continuity of symptomatology. See Voerth v. West, No. 95-904 (U.S. Vet. App. Oct. 15, 1999); McManaway v. West, No. 97-280 (U.S. Vet. App. Sept. 29, 1999); Savage v. Gober, 10 Vet. App. 488 (1997). The veteran's own opinions, statements, and testimony will not suffice to well-ground his claims. 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 asbestosis and suprasellar teratoma are related either to a disease or injury incurred during service, aggravated by service, or secondary to a service- connected disability. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The Board further finds that the RO has advised the veteran of the evidence necessary to establish a well grounded claim, and the veteran has not specifically indicated the existence of any evidence that has not already been obtained that would well ground his claim. 38 U.S.C.A. § 5103(a) (West 1991); 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). For these reasons, the Board concludes that the veteran's claims of entitlement to service connection for asbestosis and a suprasellar teratoma are not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). The Board views its foregoing discussion as sufficient to inform the veteran of the elements necessary to complete his application to reopen his claims. 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 claims for service connection of asbestosis and a suprasellar teratoma are not well grounded, the doctrine of reasonable doubt has no application to his claims. ORDER Entitlement to an rating of 100 percent for an anxiety state with an additional separate 50 percent rating for migraine headaches is granted, subject to the regulations governing the payment of monetary awards. Entitlement to service connection for a heart disability as secondary to a service connected anxiety state with migraine headaches is granted. The veteran, not having submitted well grounded claims of entitlement to service connection for asbestosis and a suprasellar teratoma, the appeal is denied. REMAND The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the Court 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. The Board initially finds that the veteran's claim of entitlement to a TDIU is well grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of increased disability is sufficient to establish a well grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). As was stated previously, the Board notes that the RO denied entitlement to a TDIU in May 1998. The veteran submitted a timely NOD with respect to the denial of a TDIU; however, there is no indication that he was ever provided with a statement of the case (SOC) pertaining to the claim for entitlement to a TDIU. When there has been an initial RO adjudication of a claim and an NOD has been filed as to its denial, the veteran is entitled to an SOC, and the RO's failure to issue an SOC is a procedural defect requiring remand. Manlincon v. West, 12 Vet. App. 238 (1999); Godfrey v. Brown, 7 Vet. App. 398, 408-10 (1995); see also Bernard v. Brown, 4 Vet. App. 384 (1993). The Board notes that the veteran's psychiatric disability has been found to be 100 percent disabling. The Board also notes that the TDIU claim was raised subsequent to the IR claim pursuant to which the 100 percent rating for an anxiety state was granted. Therefore, on remand, the RO should determine whether the issue of a TDIU has become moot in light of the assigned effective date for the 100 percent rating. With respect to the veteran's claim of entitlement to service connection for a stroke as secondary to his anxiety state with migraine headaches, the Board notes that he has consistently been documented as reporting that he suffered from a stroke in 1987, and that he has continued to have residual problems with use of his left upper extremity for activities such as writing. In his original December 1996 claim, the veteran reported incurring the stroke while being treated at the VAMC in Little Rock, Arkansas. These records are not in the claims folder, and it is unclear as to whether these records were ever requested. He has contended that the stroke was secondary to medication given to him for his migraines. Items generated by VA are held to be in "constructive possession" and must be obtained and reviewed to determine their possible effect on the outcome of a claim. Bell v. Derwinski, 2 Vet. App. 611 (1992). In August 1999 the Under Secretary for Benefits issued VBA Letter 20-99-60 in which it was stated, in pertinent part, that service medical records and VA medical center records are to be requested in all cases, as these are records that are considered to be in VA custody. See also Sims v. West, 11 Vet. App. 237 (1998). Accordingly, this case is remanded to the RO for the following: 1. The RO should request the veteran to identify the names, addresses, and approximate dates of treatment for all health care providers, VA and non-VA, inpatient and outpatient, who may possess additional records pertinent to his claims. After securing any necessary authorization or medical releases, the RO should attempt to obtain legible copies of the veteran's complete treatment records from all sources identified whose records have not previously been secured. Regardless of the veteran's response, the RO should secure all outstanding VA treatment reports. In particular, the RO should obtain 1987 medical records from the Little Rock, Arkansas VAMC. All information which is not duplicative of evidence already received should be associated with the claims file. 2. The RO should review the claims file to ensure that all of the foregoing requested development has been completed, and if it has not, the RO should implement corrective procedures. Stegall v. West, 11 Vet. App. 268 (1998). 3. With respect to the issue of entitlement to a TDIU, the RO will undertake such development or review action as it deems proper regarding this issue on appeal. This should include a determination as to whether the issue of entitlement to a TDIU is moot in light of the 100 percent rating granted for the service-connected psychiatric disability. If such action does not resolve the disagreement either by granting the benefit sought or through withdrawal of the NOD, such agency shall prepare a statement of the case, with notification of the to the veteran of his need to timely file a substantive appeal if he wishes appellate review of this claim. 4. After undertaking any necessary development in addition to that specified above, the RO should readjudicate the claim of entitlement to service connection for a stroke as secondary to a service-connected anxiety state with migraine headaches. The RO should determine whether the claim is well-grounded. If the RO determines that the claim is well-grounded, the RO should conduct any necessary development in accordance with the duty to assist under 38 U.S.C.A. § 5107(a) and then adjudicate the issue based on all the evidence. If the benefits requested on appeal are not granted to the appellant's satisfaction, the RO should issue a supplemental statement of the case containing all applicable criteria pertinent to the appellant's claim. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the appellant until he is notified by the RO. RONALD R. BOSCH Member, Board of Veterans' Appeals