Citation Nr: 0000033 Decision Date: 01/03/00 Archive Date: 12/28/01 DOCKET NO. 98-08 754A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, Puerto Rico THE ISSUES 1. Entitlement to service connection for bilateral leg amputation as secondary to service-connected varicose veins. 2. Entitlement to service connection for a heart condition as secondary to service-connected varicose veins. 3. Entitlement to special monthly compensation benefits by reason of being in need of regular aid and attendance of another person or on account of being housebound. REPRESENTATION Appellant represented by: American Red Cross ATTORNEY FOR THE BOARD C. Hancock, Counsel INTRODUCTION The veteran served on active duty from October 1940 to November 1942. The issues currently on appeal come before the Board of Veterans' Appeals (Board) from a February 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. FINDINGS OF FACT 1. The veteran has presented no competent medical evidence linking his bilateral leg amputation with his service- connected varicose veins. 2. The veteran has presented no competent medical evidence linking his heart condition with his service-connected varicose veins. 3. The veteran is currently service-connected for varicose veins, postoperative bilateral, evaluated as 60 percent disabling. 4. The veteran's service-connected disability has not rendered him unable to independently perform daily functions of self-care or to protect himself from the hazards and dangers incident to his daily environment. 5. The veteran is not housebound as a direct result of his service-connected disability. CONCLUSIONS OF LAW 1. The veteran's claim of entitlement to service connection for bilateral leg amputation as secondary to service- connected varicose veins is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The veteran's claim of entitlement to service connection for a heart condition as secondary to service-connected varicose veins is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. Special monthly compensation on account of the need for regular aid and attendance or on account of being housebound is not warranted. 38 U.S.C.A. §§ 1114(l)(s), 1502, 1521, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Generally Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. When service connection is established for a secondary condition, the secondary condition is considered as part of the original condition. 38 C.F.R. § 3.310(a) (1999). A claim for secondary service connection, like all claims, must be well grounded. Reiber v. Brown, 7 Vet. App. 513, 516 (1995). The veteran has the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that his claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). A well grounded claim is one that is plausible, capable of substantiation, or meritorious on its own. 3 8 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In a case such as this, where the determinative issue involves a question of medical causation, i.e., whether the claimed condition is etiologically linked to a service-connected disability, competent medical evidence in support of the claim is required for the VA to find the claim well grounded. See Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Bilateral Leg Amputation The veteran claims that his service-connected varicose veins caused him to have his legs amputated. Rating decisions of record confirm that the veteran has been service-connected for varicose veins since 1943. Discharge Summaries from the VA Medical Center (VAMC) in San Juan, Puerto Rico, confirm that the veteran had a right below knee amputation during an inpatient period of hospitalization between April and May 1995, and a left below knee amputation during an inpatient period of hospitalization between September and October 1995. The records did not, however, demonstrate a relationship between the veteran's service- connected bilateral varicose veins and either of the amputations. A VA diseases of the arteries and veins examination was conducted in February 1996. The examiner stated that the veteran's varicose veins did not play any role in the amputation of the right and left legs above the knees because these amputations occurred due to the peripheral vascular insufficiency due to the veteran's nonservice-connected diabetes mellitus. The Board notes that various VA outpatient treatment records dated between 1994 and 1997 have been associated with the veteran's claims folder. However, a review of these records fail to contain evidence which etiologically links the veteran's service-connected bilateral varicose veins to the bilateral leg amputations. Finally, it is noted that a medical opinion submitted by a VA rating board medical consultant, dated in February 1998, indicates that the bilateral above knee amputations was directed to treat the gangrene secondary to the vascular complications (peripheral vascular insufficiency also known as chronic arterial occlusive disease) of his nonservice- connected diabetes mellitus. The veteran has not reported that there are outstanding records that demonstrate a connection between his bilateral leg amputations and his service-connected varicose veins. The Board notes that the veteran's contentions are the only evidence linking the bilateral amputations with the service- connected bilateral varicose veins. The veteran, however, is a layperson with no medical training or expertise, and his contentions by themselves do not constitute competent medical evidence of a nexus between the bilateral leg amputations and his service-connected bilateral varicose veins. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). In the absence of competent medical evidence establishing the necessary link, the claim of entitlement to service connection for bilateral leg amputation as secondary to service-connected bilateral varicose veins is not well grounded. Furthermore, the Board is not aware of the existence of additional relevant evidence that could serve to make the veteran's claim well grounded. As such, there is no additional duty on the part of VA under 38 U.S.C.A. § 5103(a) (West 1991) to notify him of the evidence required to complete his application for service connection for the claimed disability. See McKnight v. Gober, 131 F.3d 1483, 1484-85 (Fed. Cir. 1997). That notwithstanding, the Board views its discussion as sufficient to inform the veteran of the elements necessary to well ground his claim and to explain why his current attempt fails. Heart Condition The veteran claims that his service-connected varicose veins caused him to, in essence, develop his current heart condition. As noted above, rating decisions of record confirm that the veteran has been service-connected for varicose veins since 1943. It is noted that the veteran suffers from several nonservice- connected disabilities, to include arteriosclerotic heart disease and arterial hypertension. A discharge summary from the VAMC, showing inpatient treatment afforded the veteran from March 1995 to April 1995, contains diagnoses of peripheral vascular insufficiency, toe gangrene, non-insulin dependent diabetes mellitus, hyponatremia, angina pectoris, high blood pressure, and arteriosclerotic heart disease. The record did not, however, demonstrate a relationship between the veteran's service- connected bilateral varicose veins and his heart problems. The Board notes that various VA outpatient treatment records dated between 1994 and 1997 have been associated with the veteran's claims folder. However, a review of these records fail to contain evidence which etiologically links the veteran's service-connected bilateral varicose veins to any cardiac-related condition. Finally, it is noted that a medical opinion submitted by a VA rating board medical consultant, dated in February 1998, indicates that the veteran's diagnosed arteriosclerotic heart disease and arterial hypertension are etiologically related to his nonservice-connected diabetes mellitus. It is also pointed out that the veteran has not asserted that there are outstanding records that demonstrate a connection between his heart condition and his service-connected bilateral varicose veins. The Board notes that the veteran's contentions are the only evidence linking his heart condition with the service- connected bilateral varicose veins. As was pointed out above, the veteran, however, is a layperson with no medical training or expertise, and his contentions by themselves do not constitute competent medical evidence of a nexus between a condition of the heart and his service-connected bilateral varicose veins. See Espiritu, supra. In the absence of competent medical evidence establishing the necessary link, the claim of entitlement to service connection for a heart condition as secondary to service-connected bilateral varicose veins is not well grounded. Furthermore, the Board is not aware of the existence of additional relevant evidence that could serve to make the veteran's claim well grounded. As such, there is no additional duty on the part of VA under 38 U.S.C.A. § 5103(a) (West 1991) to notify him of the evidence required to complete his application for service connection for the claimed disability. See McKnight, supra. That notwithstanding, the Board views its discussion as sufficient to inform the veteran of the elements necessary to well ground his claim and to explain why his current attempt fails. Special Monthly Compensation -- Aid & Attendance/Housebound The Board finds that the claim for entitlement to special monthly compensation by reason of being in need of regular aid and attendance of another person or on account of being housebound is "well-grounded" within the meaning of 38 U.S.C.A. § 5107 (West 1991), that is, the claim is plausible, meritorious on its own or capable of substantiation. Murphy, supra. The Board further finds that VA has met its duty to assist in developing the facts pertinent to the claim. 38 U.S.C.A. § 5107 (West 1991). As noted as part of an Informal Hearing Presentation, dated in August 1999, it is maintained that aid and attendance or housebound compensation should be granted the veteran based upon the secondary effects of his service-connected bilateral varicose veins. In this case, the veteran has one service-connected disability, bilateral varicose veins, rated as 60 percent disabling. A review of the medical record reveals that the veteran underwent bilateral above knee amputations, on two separate occasions, in 1995. Of record is a VA medical opinion, dated in February 1998, indicating that the need to amputate the veteran's legs was attributable to treatment associated with gangrene secondary to the veteran's vascular complications. It is also noted that the veteran suffers from several other nonservice-connected disorders, to include arteriosclerotic heart disease, peripheral vascular insufficiency, arterial hypertension, diabetes mellitus, nervous condition, and high blood pressure. Special monthly compensation provided by 38 U.S.C. 1114(l) (West 1991) is payable for being so helpless as to be in need of regular aid and attendance. The criteria for determining that a veteran is so helpless as to be in need of regular aid and attendance are contained in 38 C.F.R. § 3.352(a) (1999). Special monthly compensation provided by 38 U.S.C. 1114(s) is payable where the veteran has a single service-connected disability rated as 100 percent and, (1) Has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) Is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when the veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 C.F.R. § 3.350(i) (1999). The following will be accorded consideration in determining the need for regular aid and attendance: inability of claimant to dress or undress himself (herself), or to keep himself (herself) ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself (herself) through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. 38 C.F.R. § 3.352 (a) (1999). "Bedridden" will be a proper basis for the determination. For the purpose of this paragraph "bedridden" will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions which the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Id. Determinations that the veteran is so helpless, as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. Id. Initially, the Board notes that the veteran is only service- connected for one disability, bilateral varicose veins, for which he is evaluated as 60 percent disabling. As such, the requirement that the veteran have at least one service- connected disability rated at 100 percent, as needed for special monthly compensation by reason of being housebound, under 38 C.F.R. § 3.350(i) (1999), has not been met. Thus, the requirements for housebound benefits have not been met in this case. The Board has also considered special monthly compensation by reason of the need for aid and attendance. In this regard, the veteran is competent to testify as to his symptoms, see Espiritu, supra. Therefore, the Board has considered the veteran's argument on appeal that he is entitled special monthly compensation on account of being in need of aid and attendance as a result of the secondary effects of his service-connected varicose vein disability. The requirements for a grant of special monthly compensation by reason of the need for aid and attendance must meet the standards set forth in 38 C.F.R. § 3.352 (1999). In this regard, the Board notes that the veteran has one serious service-connected disability, postoperative bilateral varicose veins. However, the evidence does not show that the veteran's service-connected disability has rendered him blind, bedridden or so disabled as to be incapable of self- care. It is not claimed, nor is it shown that due to his service-connected disability, he is unable to feed himself, bathe, or dress, or care for his own hygienic needs. It is not shown that he requires assistance in using the lavatory or that the veteran is unable to protect himself from the dangers in his daily environment. It is again pointed out that the veteran has one service-connected disability. In addition, his current service-connected varicose vein disability has not been clinically demonstrated to result in functional incapacity as contemplated in 38 C.F.R. § 3.352(a) (1999). Furthermore, the evidence of record does not show that he is in need of the regular aid and attendance of another person due solely to his service-connected disability. Overall, the preponderance of the evidence is against the claim that the veteran requires personal assistance from others. As a grant of special monthly compensation based on the need for regular aid and attendance requires that service connection be in effect for a disability or disabilities which have resulted in that need, the veteran's claim must be denied. The doctrine of reasonable doubt has been considered but, as the evidence is not in relative equipoise, this doctrine is not for application. See 38 U.S.C.A. § 5107(a) (West 1991); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board finds that the record does not support a grant of entitlement to special monthly compensation by reason of being in need of regular aid and attendance or on account of being housebound. 38 U.S.C.A. §§ 1114(l)(s), 1502, 1521, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.102, 3.350, 3.351, 3.352 (1999). ORDER Entitlement to service connection for bilateral leg amputation as secondary to service-connected varicose veins is denied. Entitlement to service connection for a heart condition as secondary to service-connected varicose veins is denied. Special monthly pension by reason of being in need of regular aid and attendance of another person or on account of being housebound is denied. NANCY I. PHILLIPS Member, Board of Veterans' Appeals