Citation Nr: 0002403 Decision Date: 01/31/00 Archive Date: 02/02/00 DOCKET NO. 97-17 320A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Fort Harrison, Montana THE ISSUES 1. Timeliness of the substantive appeal filed September 12, 1994, regarding the September 9, 1993, notice of an August 1993 rating decision. 2. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for a cardiovascular disability manifested by rheumatic heart disease or mitral valve disease, and if so, whether service connection may be granted. 3. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for thoracic outlet syndrome, and if so, whether service connection may be granted. 4. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for arthritis, and if so, whether service connection may be granted. 5. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for eye disability, including post-operative residuals of exotropia, and if so, whether service connection may be granted. 6. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for typhoid, and if so, whether service connection may be granted. 7. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for salmonella, and if so, whether service connection may be granted. 8. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for hepatitis, and if so, whether service connection may be granted. 9. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for pyelonephritis, and if so, whether service connection may be granted. 10. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for a low back disability, and if so, whether service connection may be granted. 11. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for migraine headaches, and if so, whether service connection may be granted. 12. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for nasal trauma, and if so, whether service connection may be granted. 13. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for sinusitis, and if so, whether service connection may be granted. 14. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for vaginitis, and if so, whether service connection may be granted. 15. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for asthma, and if so, whether service connection may be granted. 16. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for allergic rhinitis, and if so, whether service connection may be granted. 17. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for tubal ligation, and if so, whether service connection may be granted. 18. Whether new and material evidence has been submitted to reopen the previously denied claim of entitlement to service connection for bilateral hearing loss, and if so, whether service connection may be granted. REPRESENTATION Appellant represented by: James W. Spangelo, Attorney at law WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD P.B. Werdal, Counsel INTRODUCTION The veteran served on active duty from May 1972 to August 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 30, 1993, rating decision. The record contains a document submitted as an attachment to a Department of Veterans Affairs (VA) Form 9 dated in April 1996 that raises a claim of entitlement to service connection for a right elbow disability other than an elbow fracture on a direct basis. In particular, the veteran asserted that when she hurt her right hand in service she believes she also "wrenched" her right elbow; when she fell in 1975 and injured her right foot she also hurt her "elbows;" when hospitalized in service in 1976 she fell off the toilet and injured her right elbow; she bruised her right elbow in a car accident in July 1977; and in October 1977 was treated for pain, swelling and immobility of her right elbow after injuring it while playing racquetball. She also continued her assertions that she sustained a right elbow disability that was secondary to knee disabilities, but as discussed later in this document, that claim has been addressed by the Regional Office (RO). To date, however, it does not appear that the RO has responded to the veteran's April 1996 claim that she has a right elbow disability that was directly incurred in service. As there is no Notice of Disagreement (NOD) addressing that claim, the Board has no jurisdiction over it and instead refers it to the RO for appropriate action. Ledford v. West, 136 F. 3d 776, 779-80 (Fed. Cir. 1998); Godfrey v. Brown, 7 Vet. App. 398 (1995). The Board also notes that in a document entitled "Claim," dated in August 1992, and in a document entitled "Petition to Re-open Claim," dated in December 1992, the veteran raised claims of entitlement to service connection for gastritis. To date, it does not appear the RO has addressed that claim. Accordingly, it is referred to the RO for appropriate action. Ledford; Godfrey. The Board notes that in April 1996 the veteran claimed that the RO committed clear and unmistakable error (CUE) in a 1981 rating decision. That CUE claim was denied in June 1996. In May 1997 the veteran commenced an appeal of that June 1996 determination by filing a NOD. In April 1998 the RO mailed a Statement of the Case (SOC) addressing that claim to the veteran and her attorney at their last known addresses. The cover letter accompanying that SOC advised them of the necessity of filing a substantive appeal as to that issue if one had not already been filed. An appeal of that decision has not been perfected, however, as the veteran has not filed a substantive appeal addressing that claim. Accordingly, that June 1996 denial is a final decision and will not be addressed by the Board at this time. 38 U.S.C.A. § 7105; Mason v. Brown, 8 Vet. App. 44, 56 (1995); 38 C.F.R. § 20.200. With regard to a November 1995 claim that the veteran sustained a right elbow fracture that was secondary to her knee disabilities, the Board notes that claim was denied in November 1995 because her knee disabilities were not service connected. She expressed disagreement with that determination in December 1995, was provided a SOC addressing that claim in June 1996, and perfected an appeal by filing a substantive appeal in July 1996. In a decision dated in April 1997, service connection was granted for chondromalacia of the right and left knees, with degenerative changes, rated 10 percent disabling effective from December 1991, with several periods of temporary total ratings assigned relative to the medical care administered for those disabilities. As a result of that determination, the RO reinstituted action on the veteran's claim that she has a right elbow disability secondary to her knee disabilities. In July 1997 the RO advised the veteran that, as her knee disabilities were now service connected, in order to address her claim of entitlement to service connection for her right elbow disability as secondary to her knee disabilities, VA needed medical evidence from a physician confirming her belief that a relationship exists between the disabilities of her knees and her right elbow, together with clinical treatment records used by the physician. The veteran submitted no additional evidence regarding the right elbow claim, and in April 1998 the RO notified her that it had denied the claim. The veteran has neither commenced nor perfected an appeal of that determination, nor has she attempted to reopen it, so that matter is not before the Board. The Board notes the veteran asserted in April 1996 and October 1997 entitlement to compensation under 38 U.S.C.A. § 1151 because she believed that she incurred additional disability as the result of surgery on her now service- connected left knee disability. In particular, she asserts she sustained left foot, leg and ankle disabilities as a result of surgery on her left knee to correct what is now a service-connected left knee disability. That claim was denied in April 1998, and the veteran was notified of that determination but to date has neither commenced nor perfected an appeal thereof. Accordingly, it is not before the Board at this time. In an April 1998 rating decision, the RO granted an increased rating to 30 percent for varicose veins, effective December 1995. A NOD was not filed, and that issue is not before the Board at this time. A June 1999 letter from the RO to the veteran indicates that they are currently working on her claim for an increased rating for her service-connected bilateral knee disability. That matter is referred to the RO for appropriate action. Finally, the report of a May 1997 VA compensation and pension examination reflects the examiner's assessment that severe varicose veins prevent gainful employment in the veteran's prior work as a teacher. The Board construes that as an informal claim of entitlement to total disability rating based on individual unemployability, and because there is no jurisdiction-conferring NOD regarding that claim, refers it to the RO for appropriate action. At her June 1999 hearing, the veteran indicated that she was not pursuing a claim for service connection for depression. Hearing transcript, 2. Therefore, such issue is not before the Board at this time. FINDINGS OF FACT 1. In a decision dated in August 1993 the VARO denied increased ratings for bilateral varicose veins and for residuals of an avulsion fracture of the middle phalanx palmar aspect of the left hand (minor); denied service connection for thoracic outlet syndrome, cardiovascular disease manifested by rheumatic heart disease or mitral valve disease, arthritis, post-operative residuals of exotropia, typhoid, salmonella, hepatitis, pyelonephritis, back strain, migraine headaches, nasal trauma, sinusitis, vaginitis, asthma, allergic rhinitis, exotropia, tubal ligation, bilateral hearing loss; denied special monthly compensation based on loss of use of a creative organ; and denied a compensable evaluation under 38 C.F.R. § 3.324. 2. On September 9, 1993, the veteran was notified by the RO, at her last known address, of the August 1993 decision. A NOD regarding the RO's notification dated September 9, 1993, was received by the RO January 3, 1994. A SOC addressing those claims was furnished to the veteran and her attorney on May 25, 1994. The veteran's substantive appeal dated September 12, 1994, was hand-delivered to the RO on September 12, 1994. 3. In October 1993 the RO received additional service medical records. 4. Competent evidence of in-service incurrence or aggravation of a cardiovascular disability manifested by rheumatic heart disease or mitral valve disease, or of a nexus between the veteran's current cardiovascular disability and service, has not been submitted. 5. Competent evidence of a current disability identified as thoracic outlet syndrome, and of a nexus between such disability and service, has not been presented. 6. Competent evidence of a current disability identified as rheumatoid arthritis has not been submitted, nor has competent evidence of current degenerative or traumatic arthritis of multiple joints; competent evidence of a nexus between such disability and service or between such disability and the one year period following service has also not been presented. 7. Competent evidence reveals the veteran was treated for exotropia before and after service, and the veteran's service medical records reflect she underwent several surgical procedures for exotropia in service. 8. Competent evidence of a current disability attributed to typhoid or residuals thereof, and of a nexus between such disability and service, has not been presented. 9. Competent evidence of a current disability attributed to salmonella or residuals thereof, and of a nexus between such disability and service, has not been presented. 10. Competent evidence of a current disability attributed to hepatitis or residuals thereof, and of a nexus between such disability and service, has not been presented. 11. Competent evidence of a current disability manifested by pyelonephritis and urinary tract infections, and of a nexus between such current disability and service, has not been presented. 12. Competent evidence of a current low back disability, of a back disability in service and of a nexus between the current low back disability and service has been presented. 13. Competent evidence of a current migraine disability, of in-service incurrence or aggravation of a disease or injury manifested by migraine headaches, and of a nexus between the in-service injury or disease and a current disability manifested by migraine headaches has not been presented. 14. Competent evidence of a current disability due to nasal trauma and of a nexus between that current disability and service has not been presented. 15. Competent evidence of a current disability manifested by sinusitis, and of a nexus between that current disability and service, or between that current disability and a disability incurred or aggravated in service, has not been presented. 16. Competent evidence of a current disability manifested by vaginitis, and of a nexus between that current disability and service, or between that current disability and a disability incurred or aggravated in service, has not been presented. 17. Competent evidence of a current disability manifested by asthma, and of a nexus between that current disability and service, and between that current disability and a disability incurred or aggravated in service, has not been presented. 18. Competent evidence of a current disability manifested by allergic rhinitis, and of a nexus between that current disability and service, or between that current disability and a disability incurred or aggravated in service, has not been presented. 19. Competent evidence of a nexus between the veteran's 1985 tubal ligation and service, or between that current disability and a disability incurred or aggravated in service, has not been presented. 20. Competent evidence of a nexus between bilateral hearing loss and service, or between that current disability and a disability incurred or aggravated in service, has not been presented. CONCLUSIONS OF LAW 1. A substantive appeal with respect to the September 9, 1993, notice of the August 1993 rating decision was not timely filed. 38 U.S.C.A. §§ 5107, 7105 (West 1991); 38 C.F.R. §§ 20.200, 20.201, 20.302, 20.305 (1999). 2. Service medical records received by the RO in October 1993 reopened the August 1993 rating decision. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(c). 3. The reopened claim of entitlement to service connection for a cardiovascular disability manifested by rheumatic heart disease or mitral valve disease is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). 4. The reopened claim of entitlement to service connection for thoracic outlet syndrome is not well grounded. 38 U.S.C.A. § 5107(a). 5. The reopened claim of entitlement to service connection for arthritis is not well grounded. 38 U.S.C.A. § 5107(a). 6. The reopened claim of entitlement to service connection for eye disorder, including exotropia, is well grounded. 38 U.S.C.A. § 5107(a). 7. The reopened claim of entitlement to service connection for typhoid is not well grounded. 38 U.S.C.A. § 5107(a). 8. The reopened claim of entitlement to service connection for salmonella is not well grounded. 38 U.S.C.A. § 5107(a). 9. The reopened claim of entitlement to service connection for hepatitis is not well grounded. 38 U.S.C.A. § 5107(a). 10. The reopened claim of entitlement to service connection for pyelonephritis and urinary tract infections is not well grounded. 38 U.S.C.A. § 5107(a). 11. The reopened claim of entitlement to service connection for low back disability is well grounded. 38 U.S.C.A. § 5107(a). 12. The reopened claim of entitlement to service connection for migraine headaches is not well grounded. 38 U.S.C.A. § 5107(a). 13. The reopened claim of entitlement to service connection for nasal trauma is not well grounded. 38 U.S.C.A. § 5107(a). 14. The reopened claim of entitlement to service connection for sinusitis is not well grounded. 38 U.S.C.A. § 5107(a). 15. The reopened claim of entitlement to service connection for vaginitis is not well grounded. 38 U.S.C.A. § 5107(a). 16. The reopened claim of entitlement to service connection for asthma is not well grounded. 38 U.S.C.A. § 5107(a). 17. The reopened claim of entitlement to service connection for allergic rhinitis is not well grounded. 38 U.S.C.A. § 5107(a). 18. The reopened claim of entitlement to service connection for tubal ligation is not well grounded. 38 U.S.C.A. § 5107(a). 19. The reopened claim of entitlement to service connection for bilateral hearing loss is not well grounded under either version of the applicable regulation. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Timeliness of the Substantive Appeal regarding the September 9, 1993, notice of the August 1993 rating decision Background In an August 1993 rating decision the RO denied increased ratings for bilateral varicose veins and for residuals of an avulsion fracture of middle phalanx palmar aspect of the left hand (minor); denied service connection for a cardiovascular disability manifested by rheumatic heart disease or mitral valve disease, thoracic outlet syndrome, arthritis, post- operative residuals of exotropia, typhoid, salmonella, hepatitis, pyelonephritis, back strain, migraine headaches, nasal trauma, sinusitis, vaginitis, asthma, allergic rhinitis, tubal ligation, bilateral hearing loss; denied special monthly compensation based on loss of use of a creative organ; and denied a compensable evaluation under 38 C.F.R. § 3.324. The veteran and her attorney were notified of that decision September 9, 1993, and were provided a statement of appellate rights informing them how to commence and perfect an appeal of that decision. The notice was sent to the veteran's and her attorney's addresses of record. The appellant submitted a NOD, which was received by the RO January 3, 1994. She and her attorney were furnished a SOC on May 25, 1994. The SOC was accompanied by a VA Form 9, Appeal to Board of Veterans' Appeals (substantive appeal), and the veteran and her attorney were told in a cover letter that the substantive appeal had to be completed and returned to the RO if the veteran wished to continue with her appeal. The substantive appeal was hand-delivered to the RO September 12, 1994. A VA Form 21-6789, Deferred Rating Decision, dated September 16, 1994, reported that the veteran and her attorney were advised that the substantive appeal was not timely. The hearing transcript prepared regarding the September 15 and 16, 1994, hearing officer hearing also reflects that the veteran and her attorney were advised during the hearing that the substantive appeal was not timely. They testified at the hearing and have continued to assert that it was due on Saturday, September 10, 1994, and that the attorney tried to file it Friday, September 9, 1994, but by the time he got to the VA office it had closed for the day. He waited until the following Monday, September 12, 1994, and hand-delivered it. September 12, 1994, was, in fact, the date on which the substantive appeal was filed. The veteran argues that as the substantive appeal was due on September 10, 1994, which was a Saturday, when it was hand delivered on the next workday, Monday, September 12, 1994, it was timely. In support of that argument she cites a federal rule of civil procedure, and asserts a construction of 38 C.F.R. § 20.305 that makes September 10, 1994, the due date, adjusted to September 12, 1994, the next workday. Applicable Laws and Regulations Appellate review is initiated by a timely filed NOD in writing from the appellant and, after a SOC has been furnished, a timely filed substantive appeal. 38 U.S.C.A. § 7105(a); 38 C.F.R. §§ 20.200, 20.201, 20.202. The time limit for filing a substantive appeal is one year from the date of mailing of the notice of the determination, or 60 days from the date the SOC was mailed, whichever is later. 38 C.F.R. § 20.302. Otherwise, the decision becomes final. In computing the time limit for filing a written document, the first day of the specified period will be excluded and the last day included. Where the time limit would expire on a Saturday, Sunday or a legal holiday, the next succeeding workday will be included in the computation. 38 C.F.R. § 20.305(b). The law provides that questions about the timeliness of an appeal shall be determined by the Board. 38 U.S.C.A. § 7105(d)(3). Analysis With regard to the veteran's assertions that the September 12, 1994, substantive appeal was timely, the Board has carefully considered her arguments, the evidence of record, and the applicable laws and regulations. Contrary to the veteran's assertions, the Board finds that the RO correctly applied 38 C.F.R. § 20.305(b). The first day of the one year period that began to run as the result of the mailing of the notification of the August 1993 decision on September 9, 1993, was September 9, 1993; however, that date is excluded from the one year period by 38 C.F.R. § 20.305(b). The last day was September 9, 1994, a Friday. There is no indication the veteran or her attorney requested an extension of the time for filing the substantive appeal as provided under 38 U.S.C.A. § 7105(d)(3). The veteran's substantive appeal dated September 12, 1994, was not mailed but was hand- delivered for filing September 12, 1994, after the one year period ended. Therefore, it was not timely filed. What is significant about these time requirements for filing is that they relate to the jurisdiction of the Board. If a veteran fails to complete an appeal within the required time, it is incumbent upon the Board to reject the application for review on appeal. This is not a matter within the Board's discretion; the timeliness standards for filing appeals to the Board are prescribed by law. If a claimant fails to file a substantive appeal in a timely manner, and fails to timely request an extension of time, "[s]he is statutorily barred from appealing the RO decision." Roy v. Brown, 5 Vet. App. 554, 556 (1993); cf. Rowell v. Principi, 4 Vet. App. 9 (1993). The veteran, however, has contended through her attorney at her hearing, that the Rowell case instructs that the substantive appeal is not critical to an appeal for the Board's jurisdiction and should be waived in this case. At this time in the case at hand, the undersigned does not agree. The instant case is unlike the factual situation in the Rowell case, in which there were requests for extensions of time to file the substantive appeal and the RO did not close the appeal for failure to timely file a 1-9 (substantive appeal). See Rowell, 4 Vet. App. at 16-17. Subsequently, as noted above, the Roy case elaborated that the discussion provided in Rowell could not lead to the conclusion that "the RO or the Board generally, and in all cases, has discretion to waive the express provisions of § 20.303." See Roy, 5 Vet. App. at 556. In a more recent case, the United States Court of Appeals for Veterans Claims (Court) reiterated that a "claimant must then file a substantive appeal" [after issuance of an SOC]. See Stuckey v. West, No. 96-1373 (U.S. Vet. App. November 17, 1999) at 8. The veteran's attorney also presented arguments at the June 1999 hearing that certain briefs or other communications provided to the RO in September 1993 constituted a substantive appeal. The Board notes that the SOC was not furnished to the veteran until May 1994. As provided in the regulation set forth above, a substantive appeal is filed after the issuance of an SOC. Consequently, the Board cannot conclude that communications provided earlier than the time of the SOC were a substantive appeal in response to the SOC. The Board finds that the required substantive appeal was not timely filed. The August 30, 1993, rating decision is a final determination, subject to reopening only upon submission of new and material evidence as provided in 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. Whether new and material evidence has been submitted to reopen the previously denied claims of entitlement to service connection Background The veteran served on active duty for approximately six years. The Board notes that the following disabilities have been adjudicated service-connected: bilateral varicose veins, rated 30 percent disabling since December 1995; chondromalacia of the left knee with degenerative changes, rated 10 percent disabling since December 1997; chondromalacia of the right knee with degenerative changes, rated 10 percent disabling since November 1995; residual of avulsion fracture of the middle phalanx palmar aspect of the left hand (minor), assigned a noncompensable rating since June 1980. With due consideration afforded for the bilateral factor provided by regulation, the current combined disability rating is 50 percent. In August 1993 the RO denied service connection for rheumatic heart disease, thoracic outlet syndrome, arthritis, post- operative residuals of exotropia, typhoid, salmonella, hepatitis, pyelonephritis, back strain, migraine headaches, nasal trauma, sinusitis, vaginitis, asthma, allergic rhinitis, exotropia, tubal ligation and bilateral hearing loss. The veteran and her attorney were notified of that decision in a letter dated September 9, 1993. She filed a NOD in January 1994, was provided a SOC in May 1994, and her attorney hand delivered a substantive appeal for filing on September 12, 1994. As the veteran had not perfected an appeal of the August 1993 rating decision within one year of having been provided notice of that decision, it became final and the purported substantive appeal filed in September 1994 was accepted as an attempt to reopen the August 1993 rating decision. Applicable Laws and Regulations The Secretary cannot consider a previously denied claim unless it has been reopened by new and material evidence. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.104 (1998). A three-step analysis of an attempt to reopen a previously denied claim is conducted under 38 U.S.C.A. § 5108 (West 1991). Elkins v. West, 12 Vet. App. 209, 217-218 (1999) (en banc); Winters v. West, 12 Vet. App. 203, 207 (1999) (en banc). First, it must be determined whether the evidence presented or secured since the prior final disallowance of the claim is new and material. For the purposes of determining whether new and material evidence has been submitted, the credibility of the evidence is presumed under Justus v. Principi, 3 Vet. App. 510 (1992), although patently incredible evidence is not entitled to that presumption. Duran v. Brown, 7 Vet. App. 216 (1994). Second, if the claim is reopened, VA must determine whether, based upon all the evidence of record and presuming its credible, the claim as reopened is well grounded pursuant to 38 U.S.C.A. § 5107(a) (West 1991). Third, if the claim is well grounded, it must be evaluated on its merits provided the duty to assist set out 38 U.S.C.A. § 5107(a) (West 1991) has been met. Winters. New and material evidence is evidence not previously submitted to agency decisionmakers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a). Where the new and material evidence consists of a supplemental report from the service department, received before or after the decision has become final, the former decision will be reconsidered by the agency of original jurisdiction. This comprehends official service department records which presumably have been misplaced and have now been located and forwarded to VA. Where such records clearly support the assignment of a specific rating over a part or the entire period of time involved, a retroactive evaluation will be assigned accordingly except as it may be affected by the filing date of the original claim. 38 C.F.R. § 3.156(c). Generally, for a claim to be well grounded, a claimant must submit each of the following: (1) a medical diagnosis of a current disability; (2) medical evidence, 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 in-service injury or disease and the current disability. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table), and Epps v. Gober, 126 F. 3d 1464, 1468 (Fed. Cir. 1997) (expressly adopting definition of well-grounded claim set forth in Caluza, supra), cert. denied, 524 U.S. 940 (1998). Until a well-grounded claim has been presented, VA has no duty to assist a claimant. Morton v. West, 12 Vet. App. 477 (1999), mot. for en banc review den'd July 28, 1999. In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). A layperson is qualified only to provide competent evidence of the symptoms she experiences, not of the diagnosis of an in-service disease or injury, or of a nexus between a current diagnosis and an in-service disease or injury. Falzone v. Brown, 8 Vet. App. 398 (1995); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Likewise, a lay person is not qualified to provide competent evidence that the current symptoms she experiences are related to symptoms she experienced since separation from active duty. Savage v. Gober, 10 Vet. App. 488 (1997). In this regard, the Board notes that the veteran testified that her opinions on medical matters should be afforded more weight than that afforded a layperson's opinion, as she had one year of nursing school, was a nurse in the service, and was a ski patrol after service. As a ski patrol, she contends, medical professionals relied on her assessment of an individual's medical condition when administering first aid to an injured skier. She suggests that, based on her medical background, her opinions as to medical matters are competent medical evidence thereof. Following a review of the record, the Board finds that the veteran has not established that she is a medical professional. Service records do refer to one year of college, and the veteran testified in June 1999 that the program she pursued then was nursing. However, there is no indication that she has ever completed the coursework required to receive certification or licensure as a nurse, or as any other medical professional, or that she has received such certification or licensure. Accordingly, the record does not suggest that the veteran's opinions as to matters requiring medical training can be considered competent medical evidence. See Black v. Brown, 10 Vet. App. 279 (1997). For disability resulting from personal injury suffered in the line of duty, or for aggravation of a preexisting injury suffered in the line of duty, the United States will pay compensation to any veteran thus disabled and who is discharged or released under conditions other than dishonorable from the period of service in which said injury was incurred, or preexisting injury was aggravated. 38 U.S.C.A. §§ 1110, 1131. For veterans who served 90 days or more during a period of war, if chronic diseases, such as arthritis or a cardiovascular-renal disease, become manifest to a degree of 10 percent or more within one year from the date of separation from such service, such disease will be considered to have been incurred or aggravated by such service, notwithstanding there is no record of evidence of such disease during service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Analysis The record reflects that when the August 1993 rating decision denying these claims was rendered, the RO did not have before it all of the veteran's service medical records. In particular, an envelope containing two folders with medical records dated from 1977 to 1978 regarding care administered at March Air Force Base and at Incirlik were forwarded to the RO by National Personnel Records Center in October 1993, and were received by the RO in October 1993. There is no indication that the additional medical records were considered by the RO with regard to these claims, however. That evidence is new, as it was not previously of record. It is material, as it pertains to medical care administered during service. Accordingly, the Board finds that the August 30, 1993, rating decision denying service connection for rheumatic heart disease, thoracic outlet syndrome, arthritis, post-operative residuals of exotropia, typhoid, salmonella, hepatitis, pyelonephritis, back strain, migraine headaches, nasal trauma, sinusitis, vaginitis, asthma, allergic rhinitis, exotropia, tubal ligation and bilateral hearing loss has been reopened. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. The Board notes the veteran's assertions that her complete service medical records have not been obtained. Records she submitted in November 1992 consisted of post service medical records reflecting medical care administered by the service department at a time when the veteran was not on active duty but was a dependent of an individual who was on active duty. As noted above, it does appear that when the RO adjudicated the claims in August 1993 it did not have all of the veteran's service medical records before it. However, in October 1993 the final group of service medical records was received. The Board is satisfied that it has obtained all of the veteran's service medical records. The Board notes that the RO concluded that only the rheumatic fever claim was reopened. See Supplemental Statement of the Case furnished May 1, 1997. Although the Board has decided the attempt to reopen the service connection claims differently than the RO, the veteran has not been prejudiced by the decision that these previously denied claims have been reopened, as she has steadfastly argued that each disability for which she seeks service connection was incurred or aggravated in service, that she has experienced continual symptomatology since service, and that she currently experiences disability from each condition. Based on the foregoing, the Board concludes that remand is not required under Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). Applying to these reopened claims the next step of the analysis set out in Winters, the Board must now ascertain whether the reopened claims are well-grounded as that phrase is used in 38 U.S.C.A. § 5107(a). Cardiovascular Disability The veteran's service medical records reflect that six days following entrance into active duty in May 1972 she required treatment for fainting spells, which she reported to examiners had been occurring for the last three years. She also reported no history of rheumatic fever. Upon further investigation, a systolic ejection murmur was noted, with no significant mitral insufficiency. It was concluded by the service department that the condition existed prior to service. A 1977 examination report noted a Grade II/VI holosystolic murmur heard best at the apex, and reflected the examiner's opinion that the veteran had a suspected mitral valve disease on the basis of physical examination, had a history of rheumatic heart disease, and recommended rheumatic fever prophylaxis with erythromycin. He added that the veteran should be evaluated yearly for a cardiac condition. On her separation examination in 1978 the examiner noted no murmur at that time, but that he had previously heard a heart murmur. The diagnosis was rheumatic valvular disease. An April 1979 post service medical record noted an assessment of mitral valve prolapse secondary to Marfan's syndrome. In her August 1992 brief, the veteran asserted entitlement to mitral heart disease and other heart problems, and to problems secondary to cardiovascular problems. She argued that she had no heart problems prior to her military service, but that at Lackland Air Force Base suffered a heart attack and was told she had a mitral heart murmur, which she says worsened during service. The Board notes that the medical records from Lackland dated in 1972 incident to hospitalization administered when the veteran fainted indicate a murmur was detected, but that electrocardiogram (EKG) and chest x-rays were completely normal. There is no notation in the records of a heart attack. She also asserted that she believes she had her first bout with rheumatic fever at Lackland, and as a result has rheumatoid arthritis and had to undergo a tubal ligation after the birth of her second child. The records from Lackland do not report treatment there for rheumatic fever. In an affidavit also dated in August 1992 the veteran explained that contrary to what her service medical records report, she did not have rheumatic fever as a child, was not treated for rheumatic fever as a child, and received no treatment for a heart problem until she was hospitalized at Lackland in May and June 1972. She added that she accepted discharge from active duty because of her shortness of breath, chest pains, swelling and numbness of the arms and leg, and fluid in her lungs, and partly because she believed she was going to die. She asserted that she still has the same symptoms, and has been told she might develop congestive heart disease as a result of her valve problems. A medical treatise submitted on the veteran's behalf addressed cardiovascular disabilities, but did not provide information that addressed whether this veteran currently has a cardiovascular disability that was incurred or aggravated during service. The United States Court of Appeals for Veterans Claims, formerly known as the United States Court of Veterans Appeals, (Court) has held that medical article and treatise evidence can provide important support when combined with an opinion of a medical professional, but that alone such treatise evidence cannot be used by a lay person to evaluate meaningfully the facts of a specific case because the treatise in no way addresses, let alone eliminates, the possibility of the existence of other conditions that also present the same symptomatology. Sacks v. West, 11 Vet. App. 314 (1998). The Court has recently emphasized that treatise evidence can be used to establish a well-grounded claim if it is not too general and inconclusive, and when combined with an opinion of a medical professional. Mattern v. West, 12 Vet. App. 222 (1999). To date no opinion from a medical professional has been submitted that suggests that this veteran has a cardiovascular disability that was incurred in or aggravated by service, or that was present to a compensable degree within one year following separation from service. VA medical records dated in November 1992 include a normal chest x-ray; a VA compensation and pension examination conducted that month also showed a negative cardiovascular examination. An echocardiogram performed in December 1992 noted a history of prolapse mitral valve, but reported normal structure and function. The diagnostic impression was left atrial enlargement. The veteran testified that she did not have rheumatic fever as a child. She added that her service medical records show she had a heart murmur in service, and that post-service medical records show she had one following service. She also testified that during basic training she had abscessed wisdom teeth that caused an infection in her heart, and presumably led to a heart murmur. A December 1994 statement from Dr. R reported he had been treating the veteran since 1982, that she reported a history of rheumatic fever "times two" but no history of rheumatic heart disease, and that a cardiologist reported she had Marfan's syndrome with mitral valve prolapse. It was Dr. R's conclusion within a reasonable medical certainty that the veteran does not have rheumatic heart disease. The report of a December 1994 VA compensation and pension examination performed by a rheumatologist notes a reported history of mitral valve prolapse, but made no current findings of such a condition. In an April 1995 letter, Dr. E stated that that he was not sure that the veteran would have been accepted into service if she had a heart murmur. He also indicated that he was unsure of her heart murmur at that time since he had not seen her for a number of years. He noted that when the veteran was in the hospital in 1969 there were no murmurs, thrills or cardiomegaly of the heart. As noted above, the record reflects a reference by Dr. R to a diagnosis of mitral valve prolapse made by a cardiologist. Based on that evidence, the Board finds there is competent evidence of a medical diagnosis of current cardiovascular disability, and the first step of the Caluza analysis of the well-groundedness of the claim has been met. With regard to the second step of the Caluza analysis, which requires medical evidence of in-service incurrence or aggravation of a disease or injury, there is no such evidence of record. The notations in the veteran's service medical records indicate that on the occasions that a mitral valve prolapse or rheumatic heart disease were detected, they were considered by the examiners as having existed prior to service and that there was no indication the condition had increased in severity during or as the result of service on active duty. For the reasons stated above, the veteran is not qualified to provide a competent medical opinion regarding matters requiring medical expertise, although her assertions regarding observable symptoms are competent evidence of the presence of such symptoms. Falzone; Espiritu. Furthermore, none of the post-service medical opinions attribute cardiac problems experienced at any time following the veteran's release from active duty to a disease or injury considered by a medical professional to have been incurred in or aggravated by service. The post-service evidence in April 1979 indicates that the veteran had mitral valve prolapse due to Marfan's syndrome. Marfan's syndrome is defined as a syndrome of congenital changes in the mesodermal and ectodermal tissues, and vascular defects...; autosomal dominant inheritance. STEDMAN'S MEDICAL DICTIONARY 1734 (26th Ed. 1995). This citation is provided purely for definitional purposes to aid in the Board's discussion. Cf. Kirwin v. Brown 8 Vet. App. 148 (1995), Traut v. Brown 6 Vet. App. 181 (1994). Use in this manner does not conflict with the holding in Thurber v. Brown, 5 Vet. App. 119 (1993). The Board notes that congenital defects are not considered to be a disease or injury within the meaning of applicable legislation for the payment of compensation benefits. 38 C.F.R. § 3.303(c) (1999). The 1979 medical findings also do not contain an opinion that links such identified disorders to service in any way, including by aggravation. Similarly, the April 1995 private doctor's statement lacks an opinion that relates a heart disorder to service. As such, this medical evidence is not sufficient to well ground the claim. The Board recognizes that service medical records refer to rheumatic valvular disease in 1978, prior to service separation. However, post service medical records do not support a conclusion that there is any current disability from a disorder found to be rheumatic valvular disease. That is, no current disability is shown. Dr. R's conclusion was that the veteran did not have rheumatic heart disease, and a subsequent VA examination also had no current findings. A claim for service connection for a disability must be accompanied by evidence which establishes that the claimant currently has the claimed disability. Absent proof of a present disability there can be no valid claim. See, e.g., Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ; Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). The veteran's own lay assertion that the mitral valve prolapse noted by Dr. W was incurred in service, due to rheumatic fever in service or due to the wisdom tooth infection, is not competent evidence of a nexus. See Black, 10 Vet. App. at 284. As noted above, the medical treatise evidence submitted by the veteran is not sufficient to well ground the claim without an opinion from a medical professional that provides the nexus regarding this veteran's service and a current cardiovascular disability, and to date there is no competent opinion that a nexus exists between current rheumatic heart disease or a mitral valve disease and the veteran's service. Accordingly, neither the second nor the third steps of the Caluza analysis of the well- groundedness of a claim have been met. As the veteran has not submitted evidence of a plausible claim, the Board concludes that this claim is not well grounded. 38 U.S.C.A. § 5107; Caluza. To the extent the veteran has argued that VA has failed in its duty to assist her in developing this claim, the Board explains that while VA is cognizant of its duty to assist claimants, the law requires that, absent the submission and establishment of a well-grounded claim, VA cannot undertake to assist a veteran in developing facts pertinent to her claim. Accordingly, any perceived or actual failure by VA to render assistance in the absence of a well-grounded claim cannot be legal error. As this claim is not well grounded, VA has no duty to assist the veteran. Morton, Epps. In the absence of a well-grounded claim of entitlement to service connection for a cardiovascular disability manifested by rheumatic heart disease or mitral valve disease, VA will not address the merits of this reopened claim. Winters. Thoracic Outlet Syndrome Thoracic outlet syndrome is not among the diagnoses found in the veteran's service medical records. In the October 1980 VA compensation and pension examination report the examiner noted that the veteran's arms occasionally go numb, and at the same time also get somewhat paralyzed. He added "[t]his has been diagnosed in the past as a thoracic outlet syndrome, but seems to have developed since she left the military." The veteran asserted in her August 1992 claim that the thoracic outlet syndrome diagnosed in a VA compensation and pension examination was, in fact, present in service, and that she began to drop things and get numbness in her arms "probably about the time of her hospitalization in California for the car wreck." The veteran's service medical records from March Air Force Base reflect hospitalization on three occasions for complaints of back pain, including a July 1977 hospitalization for acute cervical strain secondary to whiplash incurred in an automobile accident. None of those records contain complaints of problems with the veteran's upper extremities, only with her lower extremities and her back. In the August 1992 affidavit submitted regarding this claim the veteran alludes to injuries of the "thoratic spine" which she suggests were incurred in service. The report of a November 1992 VA compensation and pension examination makes no reference to complaints, treatment or diagnoses of thoracic outlet syndrome, by history or currently. In an October 1994 rating decision the RO concluded that evidence of a current diagnosis of thoracic outlet syndrome had not been submitted, nor was there evidence that the condition existed during service on active duty or within one year following separation therefrom. Before the Board can consider the merits of this reopened claim it must determine whether the claim is well grounded. Winters. The first step of that analysis entails consideration of whether there is a medical diagnosis of a current disability. There is not. The veteran's service medical records do not reflect complaints of, treatment for or diagnosis of thoracic outlet syndrome in service. During the VA examination performed in October 1980, more than two years following separation from active duty, the examiner made a diagnosis of thoracic outlet syndrome. However, there is no indication that the condition was present in service or within a year following separation from service. Furthermore, there is no competent evidence of record that the veteran currently has thoracic outlet syndrome and, most significantly, there is no competent evidence that, if present, it is related to service. Based on the foregoing, the Board finds that the veteran has not submitted evidence sufficient to justify a belief by a fair and impartial individual that her reopened claim of entitlement to service connection for thoracic outlet syndrome is well grounded. 38 U.S.C.A. § 5107; Caluza. In the absence of a well-grounded claim, VA has no duty to assist the claimant and will not address the merits of the claim. Morton, Epps; Winters. Arthritis of Multiple Joints In her August 1992 brief, the veteran claimed she is entitled to compensation for rheumatoid, degenerative and traumatic arthritis. In the affidavit accompanying that brief she reported that she was found to have a rheumatoid arthritis factor during a 1980 VA examination, although the Board notes that the lab sheet prepared incident to that examination reports a negative reading regarding rheumatoid arthritis. She also asserts that she contracted rheumatoid arthritis during service on active duty, and that she has had arthritis of some sort, either due to trauma or disease, in her hands, fingers, ankles, knees, elbows and back. In medical treatises submitted by the veteran addressing rheumatoid arthritis and differential diagnosis of multisystem disease, including the problems encountered when syndromes that are not clinically well defined are involved, there is provided no information useful in establishing that this veteran suffers from rheumatoid arthritis now, and that it was incurred or aggravated in service, and that there is a nexus between current rheumatoid arthritis and service. The Court has recently emphasized that treatise evidence can be used to establish a well-grounded claim if it is not too general and inconclusive, and when combined with an opinion of a medical professional. Mattern; Sacks. The veteran testified that she has arthritis in all of her joints. At page 12 of the September 1994 hearing transcript she testified that during the VA compensation and pension examination conducted in November 1992, Dr. A noted that she had painful range of motion at the joints that were fractured in service. The Board notes that the report of that examination indeed noted arthritis in the right elbow with no deformity, with pain on range of motion, and bilateral arthritis of the knees with full but painful range of motion. The veteran was unable to stand from a squatting position. The examiner also reported fractures of the left foot and ankle, but noted no deformities or residuals, and indicated "good strength." Upon examination he reported normal examination of the joints except for painful range of motion of the right elbow, left ankle and both knees, with normal feet and gait. At page 16 of that transcript the veteran testified that within one year following separation from service she was treated for "arthralgias" by the service department in Spain. Post service medical records dated as early as February 1979 note complaints of arthralgias in fingers, knees, and elbows. The assessment was possible rheumatoid arthritis. At page 33 the veteran testified that she was seeking service connection for arthritis, either rheumatoid arthritis or degenerative arthritis, and that Dr. R has been treating her arthritis with anti-inflammatory drugs. It was further asserted that she has not had a proper examination from VA that investigates the sites of arthritis. During a subsequent VA compensation and pension examination, conducted in December 1994 by a rheumatologist, the examiner reported he had reviewed the veteran's claims folder, which of course included the materials submitted by the veteran, and reported the veteran's reported history regarding her arthralgia and knee problems. After examining the veteran, the physician opined that her knee pain was due to chondromalacia patella with some degenerative disease at the patellofemoral joints, which he opined was present during service and had slowly progressed since then. He added that she had low back syndrome, which had been "present for a number of years." Regarding her hand pain, he said he could not make a diagnosis of rheumatoid arthritis either currently or in the past. He explained that the diagnosis of Marfan's syndrome may be the cause of hypermobility, which could explain many of the veteran's joint pains. Many of her findings were compatible with fibromyalgia, but he could not opine as to how long the fibromyalgia had been present. With regard to the veteran's assertion that she is entitled to service connection for rheumatoid arthritis, the Board notes that the record contains no current competent diagnosis of the presence of that disease. In the absence of such evidence, the Board concludes the reopened claim of entitlement to service connection for rheumatoid arthritis is not well grounded. 38 U.S.C.A. § 5107; Caluza; Brammer. As the claim is not well grounded, VA has no duty to assist the veteran and cannot proceed with consideration of the merits of the claim. Morton, Epps; Winters. With regard to the veteran's assertion that she has degenerative or traumatic arthritis, to the extent the knee joints are included in that claim the Board points out that the veteran is already service-connected for the degenerative arthritis in her knees. With regard to the veteran's assertion that she is entitled to service connection for degenerative or traumatic arthritis of other joints, the examiner in 1994 considered the entire record and concluded the only sites of arthritis were the knees and the right elbow. However, no examiner has linked the right elbow arthritis to service nor has it been shown that it was present to a compensable degree within one year of service discharge. In the absence of competent evidence demonstrating the requisite nexus evidence, the claim is not well grounded. (The Board otherwise points out that claims for disability of the right elbow, other than fracture residuals are addressed previously in this decision.) The 1994 examiner attributed the other complaints of pain to the veteran's Marfan's syndrome and reported that some complaints could be due to fibromyalgia, and said he was unable to diagnose the presence of rheumatoid arthritis. As noted above, the veteran is not competent to provide a current medical diagnosis. The Board notes there are indications in the veteran's post-service medical records, within one year following separation from active duty, of treatment for arthralgias and arthritis. However, it is not clear from those records which joints were involved, and as noted above the veteran is currently compensated for arthritis of the knees. The medical treatise submitted by the veteran is not accompanied by a medical opinion that links current symptomatology to symptomatology experienced since service and to an injury or disease incurred or aggravated in service. There is no basis for a conclusion that the veteran has submitted a well-grounded claim of entitlement to service connection for degenerative or traumatic arthritis of multiple joints. Mattern; Sacks; Savage v. Gober, 10 Vet. App. 488 (1997). Based on the foregoing, the Board finds that although she has reopened her claim, the veteran has not presented a well- grounded claim of entitlement to service connection for arthritis of multiple joints. 38 U.S.C.A. § 5107; Caluza. To the extent the veteran has argued that VA failed in its duty to assist her in developing this claim, the Board explains that while VA is cognizant of its duty to assist claimants, the law requires that, absent the submission and establishment of a well-grounded claim, VA cannot undertake to assist a veteran in developing facts pertinent to her claim. Accordingly, any perceived or actual failure by VA to render assistance in the absence of a well-grounded claim cannot be legal error. As this claim is not well grounded, VA has no duty to assist the veteran and cannot proceed to address the merits of the claim. Morton, Epps; Winters. Eye disability, exotropia The veteran's service medical records contain an examination conducted at the time the veteran enlisted on active duty. In it there is no indication of the presence of exotropia. In such cases, the presumption of soundness attaches. 38 U.S.C.A. § 1111. Additional medical evidence, however, clearly and unmistakably demonstrates that the condition existed prior to service. This type of evidence rebuts the presumption of soundness. 38 C.F.R. § 3.304(b) (1999). The law then provides that a preexisting injury or disease will be considered to have been aggravated by active duty 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. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1) (1999). Service medical records and a report of an examination conducted during separation from active duty in 1978 report the veteran underwent seven eye surgeries during active duty, but upon examination noted no current complaints, and no current symptoms. At page 68 of the transcript of the September 1994 hearing the veteran testified that she had several eye surgeries in service. She further testified that one surgeon in Alaska performed experimental surgery on her eyes that required subsequent corrective surgery, and that she was told by another service department physician that the surgeon in Alaska had performed "experimental nonproductive" surgery on her. In support of her claim, the veteran submitted photocopies of the definitions of diplopia, iritis, and "ectropion," and stated that she is entitled to service connection for those disabilities due to surgery, apparently in reference to the seven eye surgeries performed during service to correct exotropia. The Board notes that the definition of "ectropion" provided by appellant shows that term addresses disability of the eyelid, not the disability characterized by out-turning of the eye identified as "exotropia" in the record. It appears the definition of ectropion was submitted in error, as there is no evidence of the presence of ectropion, nor does the record contain evidence of a clear intent to apply for a benefit based on a disability manifested by ectropion. The record contains a March 1992 statement from Dr. E, who treated the veteran both before and after service for exotropia. He indicated he performed eye surgery in 1963, and then treated the veteran again in 1969 for residual out- turning and intermittent double vision, for which glasses with prisms were prescribed. In 1975 he saw her following inservice eye surgery, and then saw her beginning in 1982 for refraction. He noted that as of 1992 she still had occasional diplopia, for which glasses with prisms were prescribed. In her August 1992 brief, the veteran asserted that she is entitled to compensation for diplopia, exotropia, "iristis" and eye injuries due to service, as the pre-existing exotropia had been largely corrected prior to service. She asserts that the eye surgery she underwent in service was unnecessary and unsuccessful, and that she now has exotropia and diplopia. She adds that she should be rated for "irisitis", or unhealed injury of the eye, and for ectropion and diplopia. Based on the fact that the veteran underwent surgery for exotropia during service, and according to Dr. E's 1992 letter appears to still have manifestations of the condition, the Board finds that the veteran has presented a well- grounded claim of entitlement to service connection for exotropia on the basis of aggravation of a pre-existing condition. 38 U.S.C.A. §§ 1153, 5107; Caluza. Although the reopened claim is plausible, it is not clear from the record before the Board whether the veteran's pre-existing exotropia increased in severity during service. Accordingly, the Board finds that additional development is necessary before a decision can be made as to whether service connection is appropriate for exotropia on the basis of aggravation of that pre-existing condition. The additional development will be addressed in the REMAND portion of this document. Typhoid In June 1980 the veteran reported she was treated for typhoid and for salmonella in August 1978 in Spain. A report of an October 1980 VA compensation and pension examination it was reported by the examiner that the veteran had a typhoid infection "during her military connected period;" however, as noted above, the veteran's service medical records do not reveal that she had typhoid in service. There is no indication the examiner added medico-evidentiary value to the history regarding the purported in-service contraction of typhoid provided by the veteran, and so the evidence is not competent evidence of in-service onset of typhoid. LeShore v. Brown, 8 Vet. App. 406 (1995). In her brief, the veteran asserted she became infected with "typhoid salmonella" while on active duty in Turkey. She testified at page 50 of the September 1994 hearing transcript that she was hospitalized for this condition almost immediately following service, and so the incubation period included at least some of the time she was serving on active duty. The Board cannot find, however, records in the veteran's claims folder that reveal a diagnosis of typhoid during service. Similarly, there is no current diagnosis of typhoid, or of residuals of typhoid, nor is there a medical opinion that establishes a nexus between a current condition manifested by typhoid or its residuals and service. With regard to the veteran's assertion that she contracted typhoid during service but was not diagnosed with the disease until shortly after service, the Board notes the materials submitted in support of the veteran's claim include a definition of typhoid. That definition indicates that the causative organism of typhoid fever is salmonella typhus, and that the incubation period is from one to three weeks following exposure to infected milk or water. Although there is no medical diagnosis of typhoid per se following service, there is a diagnosis of salmonella bacteremia soon after service. However, there is no competent evidence that the veteran currently has a disability manifested by typhoid or residual thereof that was incurred or aggravated in service. In the absence of such competent evidence, the medical treatise submitted by the veteran is not sufficient to establish a well-grounded claim. Mattern; Sacks. The veteran has failed to submit evidence to justify a belief by a fair and impartial individual that she now has a disability manifested by typhoid or residuals thereof that was incurred or aggravated in service. Accordingly, the Board concludes that a well-grounded claim of entitlement to service connection for typhoid or residuals thereof has not been presented. 38 U.S.C.A. § 5107; Caluza. In the absence of a well-grounded claim, VA has no duty to assist a claimant, nor may it proceed to consider the merits of this reopened claim. Morton, Epps; Winters. Salmonella With regard to the veteran's asserted claim of entitlement to compensation for salmonella, the veteran's service medical records contain no complaints of, treatment for or diagnosis of salmonella. Her post service medical records do, however. In particular, a Clinical Record Narrative Summary dated in November 1978 regarding the veteran's August to September 1978 hospitalization contains a discharge diagnosis of salmonella bacteremia. The veteran asserts that the incubation period for salmonella is of such duration that even though she was not diagnosed with the illness until after separation from active duty, she believes she contracted the illness while still on active duty. The Board notes that a report of an October 1980 VA compensation and pension examination it was reported by the examiner that the veteran had a salmonella typhus infection "during her military connected period;" however, as noted above, the veteran's service medical records do not reveal that she had salmonella typhus in service. There is no indication the examiner added medico-evidentiary value to the history regarding the purported in-service contraction of salmonella typhus provided by the veteran, and so the evidence is not competent evidence of in-service onset of salmonella. LeShore. The veteran has submitted no medical opinion in support of her belief that the salmonella for which she was treated shortly following service was actually contracted in service, although she did submit a portion of a medical dictionary that contained a definition of typhoid fever that mentioned salmonella typhus. However, that evidence is not sufficient to well ground this claim, as it is not accompanied by competent medical evidence that this veteran has a current diagnosis of salmonella, or of residual disability that has been attributed to salmonella, nor is there a competent medical opinion that suggests a nexus between service and such residuals, if any. Mattern; Sacks; Caluza; Brammer. As the three elements of a well-grounded claim set out in Caluza have not been met by the evidence of record, the Board finds that the veteran has not presented competent evidence that her claim seeking to establish entitlement to service connection for salmonella is plausible. The Board concludes that this reopened claim is not well grounded. 38 U.S.C.A. § 5107; Caluza. Absent the submission and establishment of a well-grounded claim, VA cannot undertake to assist a veteran in developing facts pertinent to her claim, and cannot proceed to address the merits of the claim. Morton, Epps; Winters. Hepatitis Among the veteran's service medical records there is no evidence of complaints of, diagnosis of or treatment for hepatitis. Medical records dated following service reveal that she was hospitalized on two occasions in 1978 for viral hepatitis and a urinary tract infection, and once for salmonella bacteremia. The first hospitalization began 16 days following separation from active duty, and lasted 25 days, and the second hospitalization began only four days following discharge from the first hospitalization, and lasted 13 days. In her August 1992 brief, the veteran asserts that she became infected with hepatitis while serving on active duty in Turkey, and still experiences attacks of vomiting, nausea and diarrhea about once per month, when she is under stress or when she eats foods that contain grease or oil. In the affidavit that accompanied her brief the veteran added that she contracted hepatitis at the same time she contracted salmonella/typhoid. Treatises submitted by the veteran explained that viral hepatitis is an acute systemic disease caused by one of several viruses, with at least three clinically similar but epidemiologically distinct types, hepatitis A, hepatitis B and non-A non-B hepatitis, and discussed viral hepatitis and jaundice. The treatises were not accompanied by competent medical evidence that this veteran contracted hepatitis in service, and so are not sufficient to establish a well-grounded claim. Mattern; Sacks. The veteran testified that she was hospitalized for this condition soon after service, and so the incubation period included at least some of the time she was serving on active duty. She explained that two others from her squadron also contracted hepatitis B, possibly from the water in Turkey. She also testified that although VA had no copies of the medical records regarding her treatment for hepatitis, she did. She asserts that she suffers depression and stress from the hepatitis, and has some liver damage from it as well. She added that she suffers hepatitis-related stress approximately once per month. It was also contended on her behalf that she has not had the proper medical examination to identify the current symptoms, including liver damage, of hepatitis. Although perhaps the medical treatise submitted on the veteran's behalf could support a conclusion that the veteran contracted the viral hepatitis treated so soon after service during service, medical records submitted on the veteran's behalf contain no opinion that contains a current diagnosis of symptoms or manifestations attributed by medical personnel to hepatitis contracted in service, or showing continuity of symptomatology. The report of a 1980 VA compensation and pension examination notes a history of viral hepatitis contracted immediately after the typhoid and salmonella typhosa infection contracted in August 1978, with the only residual being prophylactic measures now, but there is no indication the examiner was diagnosing the presence of hepatitis in service. Rather, it appears he was acting as a scribe in reporting that the veteran contracted hepatitis after typhoid and salmonella typhus infections "during her military connected period;" there is no indication the examiner added medico-evidentiary value to the history regarding etiology provided by the veteran, and so the evidence is not competent evidence of in-service onset of hepatitis. LeShore. The only testimony in that regard is the veteran's own, and as discussed above she is not a medical professional with regard to this specialty, and cannot provide competent evidence regarding medical matters. Falzone; Espiritu. In the absence of evidence of a current disability due to viral hepatitis, and of a nexus between such disability and service, the Board finds this reopened claim is also not well grounded. 38 U.S.C.A. § 5107; Caluza. VA's duty to assist is not operative until a claim is well grounded; therefore, until the veteran presents a well-grounded claim of entitlement to service connection for residuals of hepatitis, VA has no duty to afford the veteran the examination she requested. Morton; Epps. Likewise, consideration of the merits of the claim will not proceed until a well-grounded claim is presented. Winters. Pyelonephritis and Urinary Tract Infections The veteran's service medical records reflect treatment for urinary tract infections, and contain a June 1978 diagnosis of pyelonephritis. The July 1978 separation examination report also notes that history, but reported the veteran had no complaints and no symptoms on that date. In her brief, the veteran asserted she had urinary tract infections several times during service, and with her blood pressure and edema, she believes she is entitled to service connection and a rating of 30 percent for the resulting disability. In the accompanying affidavit, she reported that she had no problems with urination or with her kidneys before service, but was diagnosed with pyelonephritis in service and was treated for infections in service. She added that she currently suffers swelling of her hand and legs when under stress or when on her feet for a long time, and believes that in conjunction with her occasional high blood pressure those symptoms are due in part to the kidney damage she sustained during service. She has submitted no evidence from a medical professional that confirms that belief, however. She testified in September 1994 that as recently as the previous winter she required treatment for this condition by Dr. R. She added that she never had a kidney problem before service, but that in service was treated on numerous occasions for urinary tract infections. At page 51 of the transcript she testified that she continued to suffer back pains that felt like kidney infections every couple of months, and is treated for kidney infections by Dr. R. She testified that as the result of kidney problems she was put on a low salt diet. A treatise submitted in support of her claim discussed infections of the urinary tract, but provided no information useful in establishing that this veteran suffers from urinary tract infections now, and that they were incurred or aggravated in service, and that there is a nexus between current urinary tract infections and service. In light of the fact that the record contains no competent medical evidence that the veteran now has a disability manifested by pyelonephritis or urinary tract infections that is related to service which could be combined with such treatise evidence, the treatise evidence is not sufficient to well ground the claim. Mattern, Sacks; Caluza; Brammer. The record does not support a finding that the veteran had a chronic disability manifested by pyelonephritis or urinary tract infections during service. The Board has also considered whether the evidence supports a finding that the veteran experienced symptoms and manifestations of pyelonephritis or urinary tract infections following service to the extent necessary to show continuity of symptomatology under 38 C.F.R. § 3.303(b). The veteran asserts she continues to suffer from pyelonephritis and urinary tract infections; however, she has submitted no competent medical evidence that her current symptoms and the symptoms she experienced in service are, in fact, related. Savage. As all three of the steps of the Caluza analysis of the well- groundedness of this reopened claim have not been met, the Board concludes the claim is not well grounded. 38 U.S.C.A. § 5107; Caluza. As this claim is not well grounded, VA has no duty to assist the veteran and cannot proceed to address the merits of the claim. Morton, Epps; Winters. Back Strain Service medical records contain diagnoses of low back pain. The report of the examination performed in July 1978 just prior to the veteran's release from active duty noted a history of injury to the mid and low back, that the veteran was wearing a back brace for support, and that she reported recurrent back pain. The diagnosis was chronic low back pain, symptomatic. In her August 1992 brief the veteran asserted she suffered a back injury in a water-skiing accident in service, and that condition worsened during service. She explained that she still suffers periodic episodes of back pain, and cannot lift anything heavy without a risk of reinjury. In the affidavit that accompanied her August 1992 brief the veteran reported that the service medical records from March Air Force Base were not available so she was not certain of the date of the water-skiing injury, but the Board notes that the March Air Force Base records have now been associated with the veteran's claims folder and reflect treatment administered to the veteran beginning September 15, 1976, for lumbosacral muscle strain associated with a water-skiing injury. As noted by the veteran in her affidavit, she was involved in a motor vehicle accident in July 1977 in which the vehicle she was operating was struck from behind and she was treated for acute cervical strain. Post service medical records dated in October 1978 and January 1979 refer to low back pain, and x-rays were interpreted to reveal no significant abnormalities. A record from Dr. C, dated in October 1983, indicates he treated the veteran following complaints of neck and low back pain attributed to a motor vehicle accident in which the vehicle she was operating was hit from behind by a police car that was traveling at a high rate of speed. In her August 1992 affidavit, the veteran reported that it was her belief that her neck was only slightly damaged in that June 1982 automobile accident, and that four months after that accident she began having pain in her lower back that was very debilitating, and was very similar to the back pain she had in Turkey. She added that she saw an orthopedic surgeon in October 1983 who told her that he doubted her lower back problem was from the 1982 accident, and that it was probably a flare-up of the 1976 water-skiing injury. The Board notes that the claims folder contains a report from Dr. C dated in October 1983 in which he reports his findings, and notes her prior history of a 1976 back injury, but does not opine that the condition he diagnosed as chronic lumbar strain syndrome in 1983 was probably a flare-up of the 1976 water-skiing injury. At her hearing in September 1994 the veteran testified that she occasionally has considerable back discomfort, and that her back is inflexible. She further explained that when she tries to lean forward her back goes "out" and causes what her doctor calls a "spasm." When this occurs she has been known to drop, and then requires help getting up. She referred to a letter from Dr. C dated in approximately 1985 that related current back problems to incidents in service. In a VA compensation and pension examination conducted in December 1994 by a rheumatologist, the examiner added that the veteran had low back syndrome, which had been "present for a number of years." The veteran has a current medical diagnosis, low back syndrome. She was treated on several occasions for back pain during service. There has yet to be added to the record, however, an opinion from medical personnel that asserts a nexus between the current low back syndrome and service. The closest item of evidence in that regard is the 1994 VA examiner's opinion that the current condition had been present for a number of years; although the "number" of years it was present was not indicated, for purposes of ascertaining whether this claim is well grounded, the Board will construe that statement in the light most favorable to the veteran. Accordingly, the Board finds that this reopened claim of entitlement to service connection for back strain is well grounded. 38 U.S.C.A. § 5107; Caluza. As the reopened claim is well grounded, the Board will proceed to consider it on its merits. Winters. VA has a duty to assist a veteran in developing a claim once that claim is well grounded. In this case, the Board notes that the record contains no opinion that clearly addresses the question of whether the veteran's current back disability and the complaints of back problems in service are linked, although the December 1994 rheumatologist opinion suggests the current back problems may be related to service. The Court has held that the duty to assist includes, in the appropriate case, the duty to conduct a medical examination to obtain such an opinion when a claim is well grounded. Hampton v. Gober, 10 Vet. App. 481, 482 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991). The Board concludes that although a well-grounded claim of entitlement to service connection for back strain has been presented, additional development is necessary before the claim can be addressed on the merits. The additional action, to be taken by the RO, will be addressed in the REMAND portion of this document. Migraine Headaches Among the veteran's service medical records is a radiographic report dated in March 1973 that reflects she was hit in the head with a rifle butt, so a skull series was ordered. The report stated the skull series was negative, with no fracture demonstrated, but that some physiologic calcification was present. Her separation examination report dated in July 1978 refers to a history of head injury in 1973 that the examiner reported resulted in an uneventful recovery, with no problems noted since, and was not incapacitating. The examination report also noted the veteran's report of frequent and severe headaches and eye problems, and indicated they were associated with the veteran's exophthalmica. In her brief and affidavit dated in August 1992, and in her hearing testimony, the veteran asserted that when she was ordered to participate in a mock riot in service she was struck in the head by a security policeman, rendered unconscious by the blow. She added that she has had migraine headaches since then, during service and afterwards. Following service she was treated for migraine headaches by Dr. R in 1986 and 1987. A treatise submitted in support of her claim discussed migraine headaches, but provided no information useful in establishing that this veteran suffers from migraine headaches now, that they were incurred or aggravated in service, and that there is a nexus between current migraines and service. The report of a December 1994 VA compensation and pension examination performed by a rheumatologist notes a reported history of occasional migraine headaches, but made no current findings of such a condition. In order to establish entitlement to service connection, the veteran must first present a well-grounded claim. 38 U.S.C.A. § 5107. As explained above, VA analyzes claims to ascertain whether they are well grounded by using the three-step analysis set out in Caluza. The first step requires a medical diagnosis of a current disability. Although there is medical evidence dated in 1987 of migraines, there is no medical evidence that the veteran has a current medical diagnosis of migraines. The veteran's service medical records contain no diagnosis of migraine headaches, although they do contain reports of headaches. The veteran asserts that the headaches she had in service were migraines, but she is not competent to make such a diagnosis, which must be made by a medical professional. Falzone; Espiritu. There is no medical evidence that opines as to whether the veteran currently has migraine headaches that are related to service. For those reasons, the Board finds the veteran has not submitted competent evidence of a current migraine disability that was incurred or aggravated in service. This reopened claim is not well grounded. 38 U.S.C.A. § 5107; Caluza; Brammer. To the extent the veteran may have argued that VA has failed in its duty to assist her in developing this claim, the Board explains that while VA is cognizant of its duty to assist claimants, the law requires that, absent the submission and establishment of a well-grounded claim, VA cannot undertake to assist a veteran in developing facts pertinent to her claim. As this claim is not well grounded, VA has no duty to assist the veteran and cannot proceed to address the merits of the claim. Morton, Epps; Winters. Nasal Trauma The veteran seeks service connection for nasal trauma, and in her August 1992 affidavit refers to the fact that on one and possibly two occasions during service her nose was broken. Examination reports prepared in October 1977 and July 1978 refer to a history of nasal fracture with an uneventful recovery, and described the nose as normal upon examination on those dates. She further asserts that since her nose fracture healed she has had intense sinus pressure when she has a head cold, and that she has severe, frequently incapacitating recurrences of sinus infection that require treatment by antibiotics that cause vaginal infections. This claim was denied in August 1993. The veteran expressed disagreement with that decision, and was provided a SOC in which it was explained that neither service medical records nor post-service medical records contain evidence of nasal trauma, including fractures. To prevail in her reopened claim of entitlement to service connection for nasal trauma, there must be current medical evidence of a disability. The record contains no such evidence. Although there is evidence in the October 1977 and July 1978 examination reports that the veteran sustained a fractured nose in service, those examination reports also reveal that her nose was normal when she was examined on those dates. Subsequent x-rays obtained incident to a VA examination were interpreted to reveal no evidence of fracture. The fact that the veteran sustained trauma to her nose during service on active duty is not enough to establish entitlement to service connection for nasal trauma; there must be a current disability. 38 U.S.C.A. § 5107; Caluza; Brammer. The only evidence in support of the veteran's assertion that she has a disability due to nasal trauma sustained in service is her own statement, and she is not qualified to provide competent evidence regarding medical matters, such as whether a current disability is linked to an injury sustained in service. Falzone; Espiritu. In the absence of competent evidence of a current disability attributed by medical personnel to nasal trauma, and in the absence of an opinion from a medical professional that provides a nexus between service and a current disability attributed to nasal trauma, there can be no well-grounded claim. Caluza. Based on the foregoing, the Board finds that the veteran has not submitted evidence to justify a belief by a fair and impartial individual that her claimed entitlement to service connection for nasal trauma is well grounded. Accordingly, the Board concludes the claim is not well grounded. 38 U.S.C.A. § 5107; Caluza. As this claim is not well grounded, VA has no duty to assist the veteran and cannot proceed to address the merits of the claim. Morton, Epps; Winters. Sinusitis The veteran asserted in her brief and affidavit dated in August 1992 that she has had problems with her sinuses since service, beginning when she was almost constantly sick with colds and fevers while stationed in Alaska, and particularly after breaking her nose on two occasions between July 1976 and July 1977. Medical records from Northern Montana Hospital dated in September 1987 reflect diagnostic impressions of recurrent sinusitis with turbinate hypertrophy. A turbinectomy was performed, and nasal antral windows were created. A pathology report regarding the turbinates indicated an area of squamous metaplasia, without atypia. No malignancy was detected in the sections examined. Even after the 1987 surgery, the veteran reported in her affidavit, she continued to experience sinus infections. She testified that in service she began having sinus problems that eventually led to surgery in 1987. A treatise submitted in support of her claim discussed sinusitis, but provided no information useful in establishing that this veteran suffers from sinusitis now, that it was incurred or aggravated in service, and that there is a nexus between current sinusitis and service. The veteran also testified that she has sinus infections approximately every three months, for which she must take antibiotics. Evidence submitted during the pendency of this claim does not reflect that the veteran has a current medical diagnosis of a disability manifested by sinusitis. The veteran's assertions in that regard are not competent medical evidence. The veteran's assertions that sinusitis that she had in service caused the nasal surgery she underwent in 1987 is likewise not competent medical evidence. Falzone; Espiritu. Finally, the veteran's assertions that she now has sinusitis and that it is related to service is also not competent evidence of such a relationship. The record contains no evidence from a medical professional that addresses the elements necessary to establish a well-grounded claim under Caluza. The medical treatise she submitted without a medical opinion is not sufficient to well ground this claim. Mattern; Sacks. Based on the foregoing, the Board finds no support in the record that would justify a belief by a fair and impartial individual that the veteran's claim of entitlement to service connection for sinusitis is well grounded. Accordingly, the Board concludes that the claim is not well grounded. 38 U.S.C.A. § 5107; Caluza. As this reopened claim is not well grounded, VA has no duty to assist the veteran and cannot proceed to consider the claim on the merits. Morton, Epps; Winters. Vaginitis The veteran's service medical records contain a report of a separation examination dated in July 1978 in which it was reported that she reported yeast infections in the past with uneventful recovery and that they were not incapacitating. In her brief and accompanying affidavit, the veteran asserted that she was diagnosed with a yeast infection in service and now has them several times a year. The veteran asserted in her affidavit and testified that the antibiotics she takes for her sinusitis puts her at risk for vaginitis. She testified that she continues to have vaginitis, for which she was first treated with prescription medication such as the one she obtained from Don's Pharmacy, and for which she can now obtain nonprescription medication. The Board notes that, if sinusitis was service connected and if it was shown by medical evidence that the treatment for sinusitis caused additional disability, such as vaginitis, service connection for that additional disability may be warranted under VA regulations. 38 C.F.R. § 3.310. A treatise submitted in support of her claim that discusses vaginal discharge also cites the use of systemic antibiotics as a common risk factor for yeast infections. However, the veteran has submitted no opinion from a medical professional that asserts that this veteran suffers from vaginitis now, and that it was incurred or aggravated in service and that there is a nexus between current vaginitis and service, or that there is a nexus between current vaginitis and the medication the veteran argues she takes to treat the sinusitis that she asserts should be service connected. The treatise evidence alone is not sufficient to well ground this claim. Mattern; Sacks. The record contains no medical diagnosis of a current disability manifested by vaginitis. As there is no medical opinion that provides the nexus opinion necessary to establish the presence of a well-grounded claim under Caluza, the Board concludes that the claim of entitlement to service connection for vaginitis is not well grounded. 38 U.S.C.A. § 5107; Caluza. As this reopened claim is not well grounded, VA has no duty to assist the veteran. Morton; Epps. The Board cannot proceed to consider the claim on the merits. Winters. Asthma In both her brief and the accompanying affidavit, the veteran asserted entitlement to compensation for asthma attacks, from which she contends she suffered in service for the first time. She added that she continues to have shortness of breath which she believes is asthma related. She submitted a treatise in support of her claim in which the topic of asthma was addressed. She testified that she never had asthma before service, but had to use inhalers in service to treat its symptoms while stationed in California and the Middle East. She added that she continues to suffer from shortness of breath, but is not sure if that is due to asthma or to cardiac problems. She testified at page 60 of the September 1994 hearing transcript that no physician had diagnosed her with asthma since service. In the absence of competent medical evidence of a current asthma disability, this claim is not well grounded. Caluza; Brammer. As the veteran has not presented competent evidence of a current disability due to asthma, or of a nexus between such current disability and service, she has not presented a plausible claim. 38 U.S.C.A. § 5107; Caluza. As this reopened claim is not well grounded, VA has no duty to assist the veteran. Morton; Epps. The Board cannot proceed to consider the claim on the merits. Winters. Allergic Rhinitis Preservice medical records include a May 1959 reference to allergy testing and complaints of a "runny nose," and subsequent preservice treatment for allergic rhinitis. The veteran's April 1972 report of medical history indicated she had a history of hay fever, which she explained was seasonal and was not treated. Service medical records note hay fever and nasal congestion in August 1972. The report of a separation examination performed in July 1978 contains a notation of seasonal hayfever since childhood, treated with relief, that existed prior to service and of which the veteran had no complaints and no symptoms on the date of examination. Post-service medical records reflect complaints of allergies and hay fever, from which the veteran reported to the examiner she had suffered since childhood. The Board notes that VA laws and regulations provide service connection for disabilities incurred in service, and for disabilities that pre-existed service but that were aggravated beyond their normal progression by service. 38 U.S.C.A. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.306. Therefore, if the veteran presents evidence sufficient to justify a belief by a fair and impartial individual that her allergic rhinitis began in service, or that it existed prior to service and was aggravated by service, she has presented a well-grounded claim of entitlement to service connection. Diseases of allergic etiology...may not be disposed of routinely for compensation purposes as constitutional or developmental abnormalities. Service connection must be determined on the evidence as to existence prior to enlistment and, if so existent, a comparative study must be made of its severity at enlistment and subsequently. Increase in the degree of disability during service may not be disposed of routinely as natural progress nor as due to the inherent nature of the disease. Seasonal and other acute allergic manifestations subsiding on the absence of or removal of the allergen are generally to be regarded as acute diseases, healing without residuals. The determination of service incurrence or aggravation must be on the whole evidentiary showing. 38 C.F.R. § 3.380 (1999). The veteran testified that she had no trouble with her nose before service, but that beginning in 1977 she carried a diagnosis of rhinitis as a routine matter. As set out above, however, the medical evidence suggests she was treated for allergic rhinitis before service. The record also suggests that, although she was treated for nasal congestion during service, there is no medical evidence that supports a finding that her pre-existing allergic rhinitis increased in severity during service. The Board notes the veteran has submitted no medical evidence of a current diagnosis of allergic rhinitis, which evidence is required to meet the first step of the Caluza analysis. She has not submitted a medical opinion that provides the nexus necessary to establish the existence of a well-grounded claim pursuant to the third step of the Caluza analysis. Based on the foregoing, the Board finds the veteran has not submitted evidence sufficient to justify a belief by a fair and impartial individual that a disability manifested by allergic rhinitis was incurred or aggravated during service, or a pre-existing allergic rhinitis condition was aggravated beyond its normal progression in service. Accordingly, the Board concludes that the claim of entitlement to service connection for allergic rhinitis is not well grounded. 38 U.S.C.A. § 5107; Caluza. As this claim is not well grounded, VA has no duty to assist the veteran under 38 U.S.C.A. § 5107, and cannot proceed to consider the claim on the merits. Morton, Epps; Winters. Tubal Ligation In the August 1992 affidavit that accompanied her brief the veteran asserted that she had been told that any pregnancy would kill her, and that both of her cardiologists gently suggested she terminate her 1981 and 1984 pregnancies. She did not do so, but after giving birth in 1985 she had a tubal ligation "solely for medical reasons." She asserts the tubal ligation was necessitated by her heart problem, which heart problem she asserts should be service connected by VA. During her September 1994 hearing the veteran testified, at page 67 of the transcript, that she was told by her treating physicians that, because of her heart problem, she should have no children. The record reflects that she had a tubal ligation in 1985. Accordingly, it appears the first step of the analysis of a claim to ascertain whether it is well grounded has been met, as the veteran has had a tubal ligation. Caluza. With regard to the second step of the well-grounded analysis set out in Caluza, the Board notes that the record clearly shows that the tubal ligation was not performed during service. If it is shown that the procedure was proximately due to or the result of a service-connected disease or injury, such as a service-connected cardiovascular disability, it may be service connected under 38 C.F.R. § 3.310(a). Service connection has not been awarded for a cardiovascular disability. The evidence of record regarding whether the procedure was necessitated by a heart condition that should be service connected consists of only the veteran's own opinion that the tubal ligation was necessary because of her heart problem, and that her heart problem was incurred or aggravated in service. As noted previously, the veteran's opinions regarding these specialized matters of medical diagnosis and causation are not competent evidence. Falzone; Espiritu. There is no competent evidence of record to support her contention that there was a nexus between the post-service tubal ligation and a disease or injury incurred or aggravated by service. The second and third steps of the Caluza analysis have not been met. Based on the foregoing, the Board concludes the veteran has failed to submit a well grounded claim of entitlement to service connection for the tubal ligation. 38 U.S.C.A. § 5107; Caluza. Accordingly, the reopened claim of entitlement to service connection for tubal ligation is denied. As that claim is not well grounded, VA has no duty to assist the claimant, and cannot proceed to consider the merits of the claim. Morton, Epps; Winters. Bilateral Hearing Loss The veteran asserts that, due to exposure to noise on the flight line during service, and also while traveling in service department aircraft, she suffered hearing loss in service and following service, and continues to experience high frequency hearing loss to the extent that she requires a hearing aid in each ear. On the authorized audiological evaluation conducted incident to the veteran's enlistment in April 1972, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 15 15 25 LEFT 20 15 10 15 25 On the authorized audiological evaluation in October 1974, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 5 5 LEFT 15 5 5 5 5 On the audiological evaluation in October 1977, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 10 10 LEFT 10 5 10 20 15 On the audiological evaluation in July 1978, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 5 5 LEFT 5 5 5 10 10 The veteran's post-service medical records reflect that in April 1979 she complained of trauma to her right ear as a cause of hearing loss. She was referred for an ear consult, where it was noted she had normal tympanic membranes and clear nasal chambers. A Rinne test was positive in all frequencies bilaterally, and repeat audiometry was ordered. Also of record is a report of a VA compensation and pension examination conducted in 1980 in which the examiner reported normal hearing and normal tympanic membranes. Private medical records dated in 1987 include pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 45 30 45 50 55 LEFT 35 25 40 55 60 Speech audiometry revealed speech recognition ability of 94 percent in the right ear and 92 percent in the left ear. A September 1987 record from Dr. F reported that the veteran had bilateral sensorineural hearing loss, and the veteran would be scheduled to receive hearing aids. During a 1992 VA compensation and pension examination it was noted that the veteran had a hearing aid in the right ear, that her canals and tympanic membranes were normal, as were bone conduction and Rinne tests. No ear discharge was noted. Service connection for bilateral hearing loss was denied in 1993 because the evidence showed no hearing loss in service, and that no hearing loss was present to a compensable degree within one year following separation from active duty. In support of her claim, the veteran submitted medical treatise evidence regarding hearing loss in connection with dizziness and vertigo. The Board finds that evidence is not relevant to the veteran's claim of entitlement to establish service connection for bilateral hearing loss. In her brief dated in August 1992 the veteran stated she had perfect pitch and perfect hearing prior to service, but was around aircraft and excessive noise during service and now believes she has lost about 40 percent of her hearing. She reported that she was wearing one hearing aid but needed another one, and that she is entitled to additional compensation because she has both hearing and vision loss. In an affidavit submitted in support of her August 1992 brief the veteran added that by the time she left active duty she had trouble distinguishing the finer sounds in some of the languages she spoke, and could no longer tune her guitar. She further asserted in both the brief and the affidavit that she was told by Dr. F in 1987 that her kind of hearing loss could have come only from a loud industrial or military environment. She argues that the only loud environment to which she was exposed was during service on active duty. In January 1993 the veteran asserted that her hearing loss claim is well grounded, and as a result VA has a duty to assist her by affording her an audiological examination. An audiological examination was conducted in March 1993. Pure tone thresholds in decibels were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 45 40 35 45 50 LEFT 55 45 55 65 60 The examiner concluded there was mild to moderately severe sensorineural hearing loss bilaterally, and that the veteran may be a candidate for amplification. The veteran testified that while in Turkey she suffered hearing loss from working on the flight line. At page 61 of the September 1994 transcript she reported that she has moderate to high frequency hearing loss in both ears, and that Dr. F had told her so. The veteran testified that when she was out on the flight line in service she was given no hearing protection, and was never told that failure to wear protection could damage hearing. She reported that she realized her hearing was damaged while still in service. She added that she sought help for her hearing loss shortly following separation from service, but not until Dr. F, an ear, nose and throat specialist, examined her in 1987 did she have extensive hearing testing done. She referred to a medical treatise that she asserts supports her claim that exposure to noise caused her current severe hearing loss. The report of a December 1994 VA compensation and pension examination performed by a rheumatologist notes the veteran was wearing hearing aids, with a reported history of having been on the flight line frequently while in the Air Force. The examiner made no current findings regarding hearing loss. Service connection may be granted for a hearing loss disability if such disability results from disease or injury incurred in or aggravated by service, or if a sensorineural- type hearing loss disability was demonstrated to a compensable degree within one year after service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. For the purposes of applying the laws administered by VA, the current version of the applicable regulation directs that impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000 or 4000 hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000 or 4000 hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (1999). The law requires that, when a law or regulation changes during the pendency of a claim and there is no provision to the contrary regarding the effective date of the change, the version most favorable to the claimant must be used. Karnas v. Derwinski, 1 Vet. App. 308 (1991). In this case, the version of the regulation in effect until the 1994 changes varied slightly from the version currently in effect. Under either version, however, the same thresholds are required to establish the presence of disability for VA purposes. After a careful review of the evidence of record, it is found that the veteran's hearing loss as measured during service was not of such severity to meet the requirements of 38 C.F.R. § 3.385. However, that is not the end of the inquiry: if the veteran currently experiences hearing loss for VA purposes that is attributed by medical opinion to service, the disability may be service connected. The 1987 private medical audiological examination and the 1993 VA examination contain evidence of the presence of disability for VA purposes. Accordingly, the first step of the Caluza analysis of a claim has been met, as there is medical evidence of current disability for VA purposes. If there was added to the record an opinion from a medical professional that asserted that the veteran's current hearing loss is due to exposure to acoustic trauma in service, that opinion could be sufficient to well ground this claim. Caluza. However, there is no such opinion of record. The Board notes the veteran's reference to medical treatise evidence, but finds that the treatise evidence submitted, alone, is insufficient to establish a well-grounded claim. Mattern; Sacks. The Board notes the veteran's assertions that she was told by Dr. F that the kind of hearing loss from which she suffers is caused by exposure to loud noises often experienced in military or industrial settings. The Board has reviewed the medical records from Northern Montana Hospital, which include records signed by Dr. F, and notes that among those records there is no mention of the source of the veteran's hearing loss. The veteran's testimony as to what Dr. F told her regarding whether her in-service exposure to high levels of noise is not sufficient to well-ground a case, as a layperson's account, filtered as it is through a layman's sensibilities, of what a doctor purportedly said is simply too attenuated and inherently unreliable to constitute medical evidence. Robinette v. Brown, 8 Vet. App. 69, 77-78 (1995). Accordingly, the third step of the Caluza analysis has not been met with regard to this reopened claim. Based on the foregoing, the Board concludes that a well- grounded claim of entitlement to service connection for bilateral hearing loss has not been submitted. 38 U.S.C.A. § 5107; Caluza. In the absence of a well-grounded claim, VA has no duty to assist the veteran. Morton, Epps. The Board is aware of the duty to inform found in 38 U.S.C.A. § 5103(a), and discussed in Robinette and Stuckey v. West, No. 96-1373 (U.S. Vet. App. Nov. 17, 1999), whereby VA is required, when a claimant's application for VA benefits is incomplete, to advise her of the evidence necessary to complete the application. The evidence necessary to complete this particular application is a statement from a medical professional that the veteran currently has hearing loss that is due to service. The statement that the veteran asserts was made to her by Dr. F was that the type of hearing loss she has is only caused by exposure to loud noises in the military or in an industrial setting. The veteran did not say that Dr. F told her that her hearing loss could only have come from her military duty, although the record reflects that the veteran herself concluded that was the case because the only exposure to loud noise she experienced was in the military. The Board finds that although there is a duty to inform a veteran when VA is on notice of the existence of evidence that would well ground a claim, in this case Dr. F's comment to which the veteran referred would not well ground the claim. Additionally, the claims file already contains the records signed by Dr. F and such records did not reflect the statements as related by the veteran. Accordingly, there is no further duty by VA under 38 U.S.C.A. § 5103(a). Stuckey; Robinette. ORDER A timely substantive appeal with respect to the September 1993 notice of the August 1993 rating decision was not filed. A well-grounded claim of entitlement to service connection for a cardiovascular disability manifested by rheumatic heart disease or mitral valve disease not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for thoracic outlet syndrome not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for arthritis not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for eye disability, including exotropia, having been submitted, to that extent the appeal is granted. A well-grounded claim of entitlement to service connection for typhoid not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for salmonella not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for hepatitis not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for pyelonephritis and urinary tract infections not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for a low back disability having been submitted, to that extent the appeal is granted. A well-grounded claim of entitlement to service connection for migraine headaches not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for nasal trauma not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for sinusitis not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for vaginitis not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for asthma not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for allergic rhinitis not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for tubal ligation not having been submitted, service connection is denied. A well-grounded claim of entitlement to service connection for bilateral hearing loss not having been submitted, service connection is denied. REMAND Because the claims of entitlement to service connection for exotropia and for back strain are well grounded, VA has a duty to assist the veteran in developing facts pertinent to those claims. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.159; Murphy v. Derwinski, 1 Vet. App. 78 (1990). As the record reflects that during service the veteran received treatment, including several surgical procedures, of her pre-existing exotropia, the Board finds that additional medical evidence is necessary to assess whether that pre- existing condition increased in severity beyond its normal progression during service, to include consideration of whether the surgeries corrected the problem and/or caused additional disability. The record before the Board does not contain a clear medical opinion addressing whether the veteran's current back disability is causally linked to service. Accordingly, this matter is REMANDED for the following action: 1. The RO should contact the veteran and her representative and provide them the opportunity to submit new medical evidence regarding the current symptoms and manifestations attributable to the veteran's eye disability and to her back strain. Only medical evidence not previously of record should be submitted. 2. The veteran should be afforded the opportunity to undergo an examination by the appropriate medical professional to identify the current symptoms and manifestations of the veteran's exotropia, and to attempt to ascertain, to the degree possible, whether the veteran's pre-existing exotropia increased in severity beyond its normal progression during service and if so, to what extent. The entire claims folder, including any materials submitted on the veteran's behalf pursuant to paragraph one hereinabove, must be made available to the examiner prior to the examination. The examiner should be asked to provide an opinion to the following: a. What eye disorder(s) pre-existed service? b. For each pre-existing eye disorder identified, did such disorder increase in severity during service? c. If an eye disorder did increase in severity in service, was the increase in severity clearly and unmistakably due to natural progression of the disorder? d. For any eye disorder that is currently present that did not pre-exist service, what is the degree of probability that such disorder is causally related to service? The examiner's opinion must be in writing, and must indicate whether the claims folder was made available for examination, and then whether the claims folder was reviewed in conjunction with the medical examination. 3. The veteran should be afforded the opportunity to undergo an examination by the appropriate medical professional to identify the current symptoms and manifestations of any and all low back disabilities, and to address, to the extent possible whether any of them, and if so which of them, are causally related to service. The entire claims folder, including any materials submitted on the veteran's behalf pursuant to paragraph one hereinabove, must be made available to the examiner prior to the examination. The examiner's opinion must be in writing, and must indicate whether the claims folder was made available for examination, and then whether the claims folder was reviewed in conjunction with the medical examination. The examiner should specifically answer the following: a. Identify all current back disabilities. b. For each back disability identified, what is the degree of probability that such disorder is causally related to service? 4. Thereafter, the RO should review the claims file to ensure that the pertinent development has been completed in full. In particular, the RO should ensure that the requested examinations are adequate and that the required opinions are responsive to and in compliance with the directives of this remand. If they are not, the RO should implement corrective procedures. 5. After the development requested above has been completed to the extent possible, the RO should again review the record and adjudicate the veteran's claim in light of all applicable law, regulations and Court cases. If any benefit sought is not granted to the veteran's satisfaction, the RO should issue a supplemental statement of the case. The requisite 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 veteran until notified by the RO; however, the veteran is advised that failure to cooperate by reporting for any scheduled examinations may result in the denial of the claim. 38 C.F.R. § 3.655 (1999). The veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims 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. M. Sabulsky Member, Board of Veterans' Appeals