Citation Nr: 0003243 Decision Date: 02/09/00 Archive Date: 02/15/00 DOCKET NO. 95-21 887 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for the cause of the veteran's death. 2. Entitlement to dependency and indemnity compensation (DIC) pursuant to the provisions of 38 U.S.C.A. § 1318. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Conner, Associate Counsel INTRODUCTION The veteran had active air service from August 1959 to July 1960. This matter comes to the Board of Veterans' Appeals (Board) from a December 1994 rating decision of the Department of Veterans Affairs (VA) Seattle Regional Office (RO) which denied service connection for the cause of the veteran's death. By January 1999 determination, the RO found that entitlement to DIC benefits pursuant to 38 U.S.C.A. § 1318 was not warranted. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appellant's appeal has been obtained by the RO. 2. The cause of the veteran's death in June 1994 was a ruptured aneurysm of the brain. 3. The evidence is in relative equipoise at to whether the veteran's service-connected psychiatric disability materially hastened his death from an aneurysm of the brain or rendered him less able to withstand the disability causing his death. CONCLUSION OF LAW Resolving the benefit of the doubt in the appellant's favor, a disability incurred in or aggravated by active service substantially or materially caused or contributed to the veteran's death. 38 U.S.C.A. §§ 1131, 1310, 5107(b) (West 1991); 38 C.F.R. §§ 3.303, 3.310, 3.312 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background The veteran's service medical records show that in April 1960, he was hospitalized with symptoms such as autistic behavior, bizarre actions, and a rich fantasy life bordering on delusional systems. The diagnosis was acute schizophrenic reaction and he was medically discharged from service. In September 1960, the veteran underwent VA psychiatric examination in connection with his claim of service connection for "nervousness." On examination, he reported that shortly after completing his basic training, he developed severe feelings of anxiety, had great difficulty sleeping, and became withdrawn. He stated that his symptoms finally led to a period of hospitalization and his discharge from service. Mental status examination showed that the veteran had free floating anxiety, although there were no delusions or hallucinations. The diagnosis was psychoneurosis, anxiety reaction. By December 1960 rating decision, the RO granted service connection for anxiety reaction, and assigned it a 10 percent rating. In October 1970, the veteran was hospitalized after a suicide attempt reportedly triggered by troubles in his marriage. On admission, he was depressed, tense, but in good contact and not grossly psychotic. The diagnosis was adjustment reaction in a latent schizophrenic. Following his discharge from the hospital, he received weekly outpatient treatment at the VA psychiatric clinic. In October 1971, he underwent VA psychiatric examination to determine the current severity of his service-connected disability. He reported continued nervousness, as well as depression, nightmares, and trouble sleeping. Mental status examination revealed increased tension, indecisiveness, and ideas of reference. Insight was fair and judgment seemed juvenile. The diagnosis was schizophrenic reaction, active, chronic. Continued psychiatric treatment was recommended. By November 1971 rating decision, the RO recharacterized the veteran's service-connected disability as schizophrenic reaction, and assigned it a 50 percent rating. In June 1994, the veteran died. The cause of his death noted on the death certificate was aneurysm rupture of the brain. At the time of his death, service connection was in effect for chronic schizophrenic reaction, rated 50 percent disabling. In August 1994, the appellant's application for DIC benefits was received at the RO with a lengthy statement outlining the circumstances surrounding the veteran's death and her theory of entitlement. In essence, she explained that in May 1994, he was wrongfully accused of molesting one of the children at a child care center where he had been working as a teacher. She stated that the ensuing investigation caused enormous stress on the veteran and, given his inability to cope with stress due to his service-connected psychiatric disability, it ultimately proved fatal. In support of this theory, the appellant submitted statements from two medical professionals. In a July 1994 statement, the veteran's treating physician of nine years indicated that in May 1994, the veteran sought treatment for depression, extreme anxiety, and psychological distress over accusations regarding sexual molestation of children at a day care center. The physician indicated that at the time of the veteran's office visit, his blood pressure was 158/110; prior to that time, it was indicated that records showed that his blood pressure had never been elevated. He stated that the veteran later was admitted to the emergency room where he was found to be markedly hypertensive. At that time, he was found to have a ruptured intercerebral aneurysm, "had surgery and never recovered and was taken off of life support and died." The physician indicated his firm belief that the veteran was tremendously distraught over the police investigation and that this caused his blood pressure to become markedly elevated. Subsequently, in September 1995, the same physician indicated that he had reviewed the veteran's medical history, including his service medical records showing a diagnosis of schizophrenic reaction. He noted that he had been the veteran's treating physician for nine years and had never observed any psychotic or schizophrenic behavior in the veteran. However, he stated that the veteran did show problems consistent with significant anxiety. He stated that "I believe that the exaggerated anxiety reaction at the time of his death was a significant factor, if not the causative factor, of his hypertension and subsequent ruptured aneurysm." In September 1995, a private clinical psychologist indicated that she had treated the veteran on two occasions during the course of the police investigation. Based on those sessions, as well as a review of the veteran's service medical records, she stated that her diagnoses would be panic disorder without agoraphobia and adjustment disorder with mixed emotional features (anxiety and depressive symptoms). She concluded that "[i]t is clear in looking through his records that whatever stress-related psychotic symptoms which may have emerged in the past and led to a diagnosis of schizophrenia, there is a clear, concurrent history of anxiety disorder and depression that can be traced through his period of military service." She further stated that the elevated blood pressure that contributed to the veteran's death was associated with that anxiety response. In October 1996, a VA physician expressed the opinion that there was no connection between the veteran's service- connected anxiety reaction and the cause of his death from a ruptured aneurysm. While he indicated that the veteran's acute hypertension, noted in May 1994, was due to acute psychological stress, he concluded that the cause of the veteran's death was a congenital brain aneurysm rupture and that it was "not probable" that mild elevations in blood pressure noted since May 1994 contributed substantially to the cause of death. II. Law and Regulations Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303 (1999). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, established that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). A disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. 38 C.F.R. § 3.310(a). Moreover, where a service- connected disability causes an increase in, but is not the proximate cause of, a nonservice- connected disability, the veteran is entitled to service connection for that incremental increase in severity attributable to the service- connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). To establish service connection for the cause of the veteran's death, the evidence must show that disability incurred in or aggravated by service either caused or contributed substantially or materially to cause death. 38 U.S.C.A. § 1310; 38 C.F.R. § 3.312 (1999). For a service- connected disability to be the cause of death, it must singly or with some other condition be the immediate or underlying cause, or be etiologically related. For a service-connected disability to constitute a contributory cause, it is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. Id. Service-connected diseases involving active processes affecting vital organs should receive careful consideration as a contributory cause of death, the primary cause being unrelated, from the viewpoint of whether there were resulting debilitating effects and general impairment of health to an extent that would render the person materially less capable of resisting the effects of other disease or injury primarily causing death. Id. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, a veteran is entitled to the "benefit of doubt" when there is an approximate balance of positive and negative evidence. The preponderance of the evidence must be against the claim for benefits to be denied. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Analysis As noted, the appellant contends that service connection for the cause of the veteran's death is warranted as his service- connected anxiety reaction rendered him materially less capable of withstanding the extreme stress of the May 1994 police investigation. She argues that this inability to cope with major stress resulted in marked hypertension and a fatal ruptured cerebral aneurysm in June 1994. The Board has carefully reviewed the medical evidence of record, with particular attention to the etiology of the veteran's fatal ruptured cerebral aneurysm. In this case, after reviewing the veteran's medical records (including his service medical records), his private treating physician of several years indicated that "I believe that the exaggerated anxiety reaction at the time of his death was a significant factor, if not the causative factor, of his hypertension and subsequent ruptured aneurysm." Likewise, in a September 1995 statement, a private clinical psychologist who had treated the veteran concluded that his medical history presented a clear picture of anxiety disorder and depression, and that the elevated blood pressure that contributed to the veteran's death was associated with that anxiety response. On the other hand, in October 1996, a VA physician indicated his belief that there was no connection between the veteran's service-connected anxiety reaction and the cause of his death from a ruptured aneurysm. While he acknowledged that the veteran's acute hypertension was due acute psychological stress, he concluded that the cause of the veteran's death was a congenital brain aneurysm rupture and that it was "not probable" that mild elevations in blood pressure noted since May 1994 contributed substantially to the cause of death. As indicated above, under the benefit-of-the-doubt rule in 38 U.S.C.A. § 5107(b), for the appellant to prevail, there need not be a preponderance of the evidence in her favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. Gilbert, 1 Vet. App. at 54. Given the medical opinions set forth above, such a conclusion cannot be made in this case. The evidence is deemed to be in relative equipoise as to whether the veteran's fatal ruptured cerebral aneurysm was causally related to his service-connected psychiatric disability. Thus, the appellant prevails in her quest for service connection for the cause of the veteran's death. Inasmuch as the Board's decision above constitutes a full grant of the benefit sought on appeal with respect to the issue of service connection for the cause of the veteran's death, the issue of entitlement to DIC under the provisions of 38 U.S.C.A. § 1318 is rendered moot, as the appellant would be entitled to no additional benefits by virtue of a grant of DIC under the provisions of 38 U.S.C.A. § 1318. See Mintz v. Brown, 6 Vet. App. 277 (1994) (the Board does not have jurisdiction to review a case if no benefit would accrue to the claimant). ORDER Service connection for the cause of the veteran's death is granted. J.F. GOUGH Member, Board of Veterans' Appeals