Citation Nr: 0002014 Decision Date: 01/27/00 Archive Date: 02/02/00 DOCKET NO. 96-13 822A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for the cause of the veteran's death. 2. Entitlement to dependency and indemnity compensation (DIC) pursuant to the provisions of 38 U.S.C. A. § 1318 (West 1991). REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Odlum, Associate Counsel INTRODUCTION The veteran had active military service from July 1962 to February 1967. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 1995 rating decision of the Waco, Texas Department of Veterans Affairs (VA) Regional Office (RO). The RO denied entitlement to service connection for the cause of the veteran's death, DIC pursuant to the provisions of 38 U.S.C.A. § 1318, but granted entitlement to Chapter 35 Dependents' Educational Assistance. In June 1999, the RO appeared to inadvertently indicate that entitlement to such benefits had not been established. As the record shows that these benefits had already been granted in April 1995, the Board concludes this issue is not before the Board. The Board notes that additional evidence has been submitted to the Board, some of which was not first considered by the RO; however, the appellant submitted a statement with this evidence waiving RO consideration of such evidence. 38 C.F.R. § 20.1304(c) (1999). FINDINGS OF FACT 1. All available relevant evidence necessary for an equitable disposition of the appellant's claim has been obtained by the RO. 2. The probative evidence of record does not show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 3. The probative evidence of record does not show that the veteran was in receipt of or entitled to receive compensation at the time of death for service-connected disability that was rated totally disabling on either a schedular or unemployability basis for a period of 10 years immediately preceding death, or that he was so rated for a period of not less than 5 years from the date of his discharge or other release from active duty. CONCLUSIONS OF LAW 1. The cause of the veteran's death is not related to an injury or disease incurred during active service. 38 U.S.C.A. §§ 1110, 1112(c)(1), 1310, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.309(d), 3.310, 3.311, 3.312 (1999). 2. The criteria for a grant of entitlement to DIC benefits pursuant to 38 U.S.C.A. § 1318 have not been met. 38 U.S.C.A. §§ 1318, 5107(a) (West 1991); 38 C.F.R. § 3.22 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Entitlement to Service Connection for the Cause of the Veteran's Death Factual Background The veteran's death certificate shows that he died in November 1994, with the immediate cause of death listed as arteriosclerotic coronary artery disease. No underlying or contributory causes were listed, and the manner of death was noted as being natural. Service medical records show no documentation of a heart disorder, including coronary artery disease. In particular, the enlistment and separation examinations noted that the veteran's heart and vascular systems were normal. Service medical records are negative for a diagnosis of a mental impairment. Service records indicate that he underwent basic training in July 1962 and was stationed in New London, Connecticut from November 1962 to October 1963, and at the U.S. Naval Station (USNS) in Argentia, Newfoundland from January 1964 to approximately March 1965. He was aboard the USS CARRONADE from approximately November 1965 to December 1966. Service records show that the veteran was disciplined for underage consumption and possession of alcohol in June 1964 while stationed at the USNS in Argentia, Newfoundland. He was again disciplined in June 1964 while drunk in his quarters. He was disciplined in July 1964 for being drunk while on duty at the USNS in Argentina, Newfoundland. He was disciplined in July 1965 for consumption of alcoholic beverages by a minor while in Tijuana, Mexico. Following his discharge from service, the veteran was admitted to Big Spring, Texas VA Medical Center (VAMC) in January 1981 for alcoholism and alcohol abuse. He was admitted to the detoxification area and given medication for withdrawal. In February 1986 the veteran was admitted to the VAMC in Salt Lake City for complaints of shortness of breath and increased dyspnea on exertion. He admitted to heavy drug use with speed. During his admission, pulmonary function testing revealed moderate obstruction. It was thought that this was secondary to silicosis and chronic obstructive pulmonary disease (COPD). He was found to be positive for "PPD," and was also noted as having headaches. It was noted that he had a history of recurrent meningitis. The discharge diagnoses were continuous amphetamines dependence, other mixed substance abuse, antisocial personality features, tension headaches, a history of erosive gastritis, a history of hepatitis (1968), a history of recurrent meningitis, and anisocoria secondary to trauma. The veteran was admitted to the VAMC in April 1989 for treatment of alcohol dependence. A long history of excessive drinking, worse over the past four years was noted. He reported that he started drinking at the age of 16 and that this continued through the military service to the present time. It was also reported that his father and one brother were alcoholics who committed suicide. The diagnosis, in pertinent part was continued alcohol dependence. In August 1989 the veteran was admitted to a VAMC for nausea and vomiting. He was treated for persistent nausea and vomiting secondary to alcohol gastritis and metabolic alkalosis secondary to the first diagnosis. In February 1990 the veteran was admitted to the Louisville VAMC for treatment of alcohol abuse and dependence, and major depression. It was noted that he was intoxicated and expressing suicidal ideation. In August 1990 the veteran was admitted to the Louisville VAMC for treatment of alcohol abuse and intoxication as well as major depression. He was noted as having suicidal ideations and alcohol withdrawal on admission. The veteran was treated and was noted on discharge as having a brighter affect. It was also noted that he was detoxified of alcohol. In January 1991 the veteran was admitted to the Louisville VAMC for alcohol detoxification. Suicidal ideation with no plan was noted on admission. During the admission, the veteran reported that his father and brother had committed suicide and that his mother and another brother had died in a car accident. The diagnosis was "ETOH" abuse/dependence. The veteran was seen at the VAMC in Oklahoma City in May 1991 with depression and suicidal ideation. A decreased appetite and alcohol consumption were noted. He reported that he did not want to die but that he did not want to feel the way he did. The veteran was admitted for alcohol detoxification. It was noted that he was drinking excessively on a daily basis with frequent blackouts. He reported that he started drinking as a teenager and that he drank heavily while in the service. Examination of the heart revealed a regular rate and rhythm with no thrills, murmurs, or gallops. The diagnoses were, in pertinent part, continuous alcohol dependence, alcohol withdrawal, and alcoholic gastritis. The veteran submitted a claim for service connection of post- traumatic stress disorder (PTSD) in June 1991. In August 1991, the veteran underwent a VA psychiatric examination during which he was diagnosed with a major depressive disorder, recurrent and chronic, and a mixed personality disorder. During the examination, he reported that he was in and out of Vietnam over a period of about two years from 1965 until 1966. He stated that he was the engineer on a 90 man crew for a river boat giving fire support to troops on shore. In August 1991 (received by the RO in February 1993), the veteran was seen for difficulty with his lungs. A history of silicosis was noted, which he stated was the result of running a sandblaster. It was also noted that he was a long- term heavy smoker at a rate of about two or three packs a day for 33 years. He stated that he had cut back recently. A chest x-ray was found to reveal a normal chest. Blood pressure was 132/92 sitting and 132/92 standing. The impression was shortness of breath (said to be due to silicosis), abdominal pain and vomiting of undetermined etiology, and subjective instability of the left knee. The veteran underwent a psychiatric evaluation in August 1991 (received by the RO in February 1993). He reported having a problem with his nerves and that it was hard for him to deal with people. He denied any history of hypertension, diabetes, renal, or blood diseases. During the evaluation, the examiner indicated his suspicion that depression ran in the veteran's family. The veteran was noted as reporting that his younger brother was a drug abuser. Also noted was a history of alcohol abuse. The VA examiner concluded that the veteran was unable to manage his own benefit payments because of poor judgment. The diagnoses were alcohol dependency, depressive disorder, borderline personality disorder, avoidant personality disorder, and anti-social traits. In November 1991 (received by the RO in February 1993), the veteran was admitted to a hospital by the police after reportedly holding his family at gunpoint and threatening to kill them if the officers came to his house. It was noted that he had been drinking heavily. He denied suicidal or homicidal ideations on admission. It was also noted that he had bronchi in his lungs. He was treated and discharged with diagnoses of alcohol dependence, anti-social personality, and chronic bronchitis. In March 1992 (received by the RO in February 1993) the veteran underwent a psychiatric evaluation. He reported being depressed all of his life. A history of suicide in the family was noted. The examiner concluded that there was clearly a history of mental illness and substance abuse with the veteran's father and brothers. The veteran stated that he thought about suicide every day, but had not formulated any specific plans. It was concluded that he did not represent an acute suicide risk. The diagnoses were dysthymic disorder and generalized anxiety disorder. In July 1992 a VA general mental disorders examination was conducted. A history of substance abuse was noted and the impression was substance abuse (multiple drugs and probable alcohol), and depression, major with a moderate incapacity to work and a moderately severe incapacity to socialize. In June 1993, a psychological evaluation was conducted. On examination, the veteran reported being sent to Vietnam in 1965 where he was assigned to the USS CARRONADE. He recalled an incident while in Vietnam in which he shot people, and that he got drunk following this incident and had been getting drunk ever since. The diagnoses, in pertinent part, were PTSD, alcohol dependence, and depression. In August 1993 the veteran was admitted to a VA hospital for treatment of PTSD symptoms. He also reported a history of having atrial fibrillation and benign essential hypertension. He also reported that he had been drinking since 1962. The pertinent diagnoses on discharge were PTSD, episodic alcohol abuse, atrial fibrillation, and benign essential hypertension. In November 1993, the veteran underwent a VA examination for PTSD. Symptoms of PTSD were noted as well as alcohol consumption. He reported thinking about suicide but stated that he had to take care of his family. He reported a history of PTSD symptoms relating to his service in Vietnam. The pertinent diagnoses were chronic PTSD with marked depression and continuous alcohol dependence. It was indicated that the veteran did not have the capacity to maintain employment or social adaptation due to his PTSD. In April 1994, the RO granted service connection for PTSD, assigning a 100 percent rating, effective June 14, 1991, the date the RO received the veteran's claim for PTSD. The veteran was not service connected for any other diseases or injuries. In August 1994, the veteran was admitted to a VAMC and treated for alcohol withdrawal, chronic alcohol abuse, and alcoholic gastritis. He reported a history of alcoholism for the past 30 years. Progress notes from this admission indicated that the veteran was at times confused, verbally abusive, and belligerent. As was stated above, the veteran died in November 1994, with the death certificate listing arteriosclerotic coronary heart disease as the immediate and only cause of death. The autopsy report from November 1994 revealed "several arteriosclerosis" on sectioning, with focal restriction of the lumen by 80 percent of the left anterior descending artery. A section taken of the liver showed moderate steatosis. A section from the lungs showed mild focal infiltration. The findings were severe arteriosclerosis of the coronary arteries and focal pneumonia. The medical examiner, Dr. J-L.Z. concluded that the veteran died of arteriosclerosis of the coronary arteries. Toxicology of the blood was negative for alcohol. In February 1995, Dr. R.A.T. wrote that she first saw the veteran in January 1993 and that he was severely depressed and drinking heavily. She noted that he at one point was actively seeking a gun to commit suicide. She reported that he never came back to her office, but that his family was continuing to see her and inform her of the veteran's problems. Dr. R.A.T. concluded that she was convinced that the veteran had been treating his depression with alcohol and that it was his alcoholism which lead to his demise. In April 1995, the appellant filed a claim alleging service connection for the cause of the veteran's death. In June 1995 the appellant submitted a statement essentially contending that the veteran's death was a form of suicide. She stated that the veteran had wanted to kill himself, and that in the 12 days prior to his death, he had sat on their couch and refused to eat. She concluded that this act, combined with his excessive drinking, stressed his heart and caused him to die. She indicated that the veteran's behavior was due to psychological problems resulting from his PTSD symptoms. In May 1996 an article was received which concluded that intense psychological stress may trigger episodes of irregular heart rhythms that lead to sudden death. It was noted that anxiety was proving to be one of the strongest risk factors for sudden cardiac death. In May 1996 the RO received a statement from Dr. L.S., dated in September 1995, in which he concluded that the veteran's PTSD was severe enough to cause his alcoholism and heart disease. He added that these problems were more likely than not caused by PTSD. In August 1998 a VA examiner provided an opinion noting that the veteran's death was due to atherosclerotic coronary artery disease. She found that there had been no research to date proving that PTSD causes coronary artery disease. In rendering this conclusion, the examiner indicated that she had reviewed the claims folder, noting that the veteran had once reported that he had started drinking at the age of 16. She also noted that there was a family history of alcoholism. She concluded that alcoholism was present before his service and was not caused by PTSD. In March 1999 an article dated from July 1989 was received by the RO. The article related to a World War II prisoner-of- war (POW) veteran who was being treated for depression and PTSD. The author concluded that the veteran's wartime experience as a POW played a causative role in his eventual development of hypertension. He also concluded that PTSD placed the veteran at an increased risk for developing hypertension. Another article received in March 1999 indicated that chronic stress can lead to a number of psychosomatic or psychophysiological problems including, in pertinent part, high blood pressure or hypertension. It was found that hypertension could in turn lead to arteriosclerosis, strokes, and kidney malfunctions. In September 1999 a hearing at the RO before a travel Member of the Board was conducted. The representative initially contended that the August 1998 VA opinion was inadequate because it did not cite to both medical opinions linking the cause of death to PTSD and alcohol consumption. Transcript, p. 2. The Board also notes that the representative had previously contended in a VA Form 646 that the VA opinion was based on faulty assumptions, namely that the veteran's brother and father were alcoholics. The appellant testified that the veteran was treated by Dr. L.S. off and on while they were living at Lake Arrowhead, and that he saw him quite frequently in the last two or three years before he died. Tr., p. 3. She testified that the veteran had spent time talking about suicide in the several days prior to his death. She stated that he refused to get off the couch and refused to eat food for the 12 days leading up to his death. Tr., p. 6. She testified that the veteran told her that he was "tired of it," tired of thinking about the people he killed while he was in Vietnam. Tr., pp. 6-7. She stated that he would drink and pass out to avoid dealing with such feelings. See Tr., p. 7. The appellant testified telling the veteran that it looked like he was trying to kill himself by not eating, and that the veteran responded that he could end it "real fast" if she would bring him a gun. The appellant testified that she was unable to do this for him. Tr., p. 8. Criteria A claim for service connection for the cause of death is treated as a new claim, regardless of the status of adjudication of service-connected-disability claims brought by the veteran before his death; therefore, the claim must be well-grounded. See Lathan v. Brown, 7 Vet. App. 359 (1995); 38 C.F.R. § 20.1106 (1999). The United States Court of Appeals for Veterans Claims (Court) has held that a well grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of § [5107(a)]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The Court has articulated the requirements for a well grounded claim for service connection as follows: (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and, (3) medical evidence of a nexus between the claimed inservice injury or disease and a current disability. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). In order to establish service connection for a claimed disability the facts must demonstrate that a disease or injury resulting in current disability was incurred in the active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. § 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Continuous service for 90 days or more during a period of war, and post-service development of a presumptive disease to a degree of 10 percent within one year from the date of termination of such service, establishes a presumption that the disease was incurred in service. 38 C.F.R. §§ 3.307, 3.309 (1999). If not shown in service, service connection may be granted for arteriosclerosis if shown disabling to a compensable degree during the first post service year. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Service connection may also be granted for disability, which is proximately due to, or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a) (1999). When there is aggravation of a nonservice-connected condition, which is proximately due to, or the result of service-connected disease or injury, the veteran will be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). In cases of service connection for the cause of death of the veteran, the first requirement of a current disability will always have been met, the current disability being the condition that caused the veteran to die; however, the last two requirements for a well-grounded claim must be supported by the record. Carbino v. Gober, 10 Vet. App. 507, 509 (1997). In order to establish service connection for the cause of the veteran's death, the evidence must show that a disability incurred in or aggravated by active service was the principal or contributory cause of death. 38 U.S.C.A. § 1310 (West 1991); 38 C.F.R. § 3.312(a) (1999). In order to constitute the principal cause of death the service-connected disability must be one of the immediate or underlying causes of death, or be etiologically related to the cause of death. 38 C.F.R. § 3.312(b) (1999). Contributory cause of death is inherently one not related to the principal cause. In order to constitute the contributory cause of death it must be shown that the service-connected disability contributed substantially or materially; that it combined to cause death; that it aided or lent assistance to the production of death. It is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 C.F.R. 3.312(c). If the service-connected disability affected a vital organ, careful consideration must be given to whether the debilitating effects of the service-connected disability rendered the veteran less capable of resisting the effects of other diseases. There are primary causes of death which by their very nature are so overwhelming that eventual death can be anticipated irrespective of coexisting conditions, but, even in such cases, there is for consideration whether there may be a reasonable basis for holding that a service- connected condition was of such severity as to have a material influence in accelerating death. In this situation, however, it would not generally be reasonable to hold that a service-connected condition accelerated death unless such condition affected a vital organ and was of itself of a progressive or debilitating nature. 38 C.F.R. § 3.312(c)(3), (4) (1999); Lathan v. Brown, 7 Vet. App. 359 (1995). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the appellant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Analysis Initially, the Board finds that the appellant's claim for service connection for the cause of the veteran's death is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). The appellant has presented medical evidence in the form of physician opinions indicating a possible link between the veteran's PTSD and the cause of death. The Board also notes that the appellant has testified that she worked for many years as a nurse's aid in hospital settings and in nursing home settings. Transcript, p. 7. The Board is also satisfied that all relevant facts have been properly developed, and that no further assistance is required in order to satisfy the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). In this regard, the Board notes the appellant's reference to Dr. G.H. in her VA Form 9. She stated that Dr. G.H. was the veteran's VAMC physician in September 1994. The appellant stated that Dr. G.H. told her over the phone that the veteran would die within six months if he did not stop drinking. The appellant stated that Dr. G.H. was no longer with the Oklahoma City VAMC and that she was unable to locate her. The Board concludes that the duty to assist does not attach to the statement of Dr. G.H. With regard to the retrieval of relevant records, the record should show at least the possibility that the records exist. In this case, the appellant stated that Dr. G.H.'s statement was made over the phone. She has also stated that she is unable to locate Dr. G.H. and that she is no longer with the VAMC. In addition, records from the Oklahoma City VAMC have been obtained by the RO. The duty to assist is not a license for a "fishing expedition" to ascertain whether there might be unspecified information which could possibly support a claim. Gobber v. Derwinski, 2 Vet. App. 470, 472 (1992); see e.g., Counts v. Brown, 6 Vet. App. 473, 476 (1994). The truthfulness of evidence is presumed in determining whether a claim is well grounded. Meyer v. Brown, 9 Vet. App. 425, 429 (1996). However, the presumption of credibility does not extend to the point beyond which it is determined that a claim is well grounded. King v. Brown, 5 Vet. App. 19, 21 (1993); Chipego v. Brown, 4 Vet. App. 102, 104-105 (1993). In a claim that has been found to be well-grounded, the Board is required to consider and discuss all evidence on both sides of the issue, and to reconcile any conflicts among such evidence, or, alternatively, provide an explanation of the reasons for rejecting evidence favorable to the appellant or determining that such evidence is of little relative weight or probative value. Quiamco v. Brown, 6 Vet. App. 304, 308 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board initially notes that the evidence does not show that the veteran had a cardiac condition (including arterial hypertension) or arteriosclerotic coronary artery disease during or within one year after service. 38 C.F.R. § 3.309 (d). After a careful review of the record, the Board concludes that a preponderance of the medical evidence demonstrates that the cause of the veteran's death was not incurred in or was a result of service. The appellant contends that the veteran's PTSD and alcoholism (she also has indicated that his alcoholism was secondary to his PTSD) contributed to the cause of death, arteriosclerotic coronary artery disease. She contends that the veteran's death resulted from his act of starvation (not eating food) for 12 days prior to his death, and his excessive alcohol use. In this regard, she indicates that his alcoholism and act of starvation were secondary his service-connected mental disability. In support of her claim, the appellant has submitted private and VA medical records, including two medical opinions linking the cause of death to PTSD and to alcoholism via the veteran's psychiatric disability. In a letter dated in February 1995, Dr. R.A.T. indicated her opinion that the veteran's alcoholism was the primary reason for the veteran's death, and that the veteran's alcoholism was secondary to his severe depression in that he had been treating his depression with alcohol. In September 1995, Dr. L.S. concluded that the veteran's PTSD was severe enough to cause alcoholism and heart disease and that these problems were more likely than not caused by his PTSD. On the other hand is the medical opinion provided by a VA examiner in August 1998 in which it was concluded that there was no research proving that PTSD causes coronary artery disease. The VA examiner noted Dr. L.S.'s conclusion linking PTSD to alcoholism and heart disease. The VA examiner concluded the alcoholism was not caused by PTSD as the record showed that he began drinking prior to entering the service. The examiner concluded that the alcoholism was present before the military service, also noting that there was evidence of a familial history of alcoholism. The Board attaches greater probative weight to the August 1998 VA examiner's opinion. First, the VA examiner indicated that she had reviewed the claims folder. Neither Dr. R.A.T. nor Dr. L.S. indicated that they had reviewed the claims folder in making their conclusions. Second, the VA examiner's conclusions are supported by the medical evidence of record. The record has documented a long history of alcoholism, and the veteran indicated on more than one occasion that he began drinking prior to entering the service. The veteran also reported a history of in-service alcoholism dating back prior to his service in Vietnam, when his PTSD stressors occurred. Service records indicate that the veteran was disciplined for alcohol-related infractions prior to serving in Vietnam. Thus, the record and the veteran's own statements lend support to the VA examiner's opinion that alcoholism was not caused by PTSD, as the evidence supports the conclusion that he was abusing alcohol prior to the occurrence of the Vietnam-related stressors reported by the veteran in November 1993, which lead to the diagnosis of PTSD. Furthermore, neither the autopsy report nor the death certificate documented that alcohol or alcoholism contributed to the cause of death. Additionally, there is no medical evidence supporting the appellant's contention that the veteran's 12 day abstention from food prior to his death resulted in or contributed to the cause of death. Finally, the opinions of Dr. R.A.T. and Dr. L.S. are entitled to little probative weight because neither indicated that they had treated the veteran for any kind of heart disorder or that they treated him for any consistent length of time. Dr. L.S. reported that he had treated the veteran in 1991 and 1991 for alcoholism and esophagastric problems. He did not indicate that he treated or specifically examined the veteran for heart disease. In addition, Dr. L.S. did not support his conclusions with any of his own clinical findings or other evidence that would support such a conclusion. Similarly, Dr. R.A.T. indicated that she had seen the veteran on only one occasion (January 1993), and the information regarding his problems was subsequently related to her through the veteran's family. Dr. R.A.T., a psychologist, did not indicate that she had treated the veteran for any heart problems. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that it is not error for the Board to favor opinion of one competent medical expert over that of another when the Board gives adequate statement of reasons and bases). The appellant's representative has contended that the VA examiner's conclusions were based on faulty assumptions. The representative contended that neither the veteran's father or brother were alcoholics and that the VA examiner did not cite to the statement of Dr. R.A.T. in making her conclusion. First, the record has documented on more than one occasion the veteran's report that he had a brother and father who were alcoholics. In addition, at least one physician has concluded that there was evidence of substance abuse in his family. Therefore, the VA examiner's conclusions were not based on an assumption, but were based upon actual documentation in the record. Second, the VA examiner's lack of a specific citation to Dr. R.A.T.'s opinion in this instance does not lessen the value of his opinion because Dr. R.A.T.'s opinion essentially makes the same contention as the opinion made by Dr. L.S., who was cited to by the VA examiner. Both opinions linked the cause of death to the veteran's mental disability, and both linked his alcoholism to his mental disability. Furthermore, the VA examiner cited to specific evidence in the record in support of her conclusions, indicating that she did in fact review the claims folder in making her determination. The appellant has also submitted three medical treatises in support of her claim. These treatises are of little probative value as they either do not refer to arteriosclerotic heart disease or are too general and inconclusive to help establish service connection for the cause of the veteran's death. See Wallin v. West, 11 Vet. App. 509, 513 (1998); Sacks v. West, 11 Vet. App. 314, 317 (1998). One article linked anxiety with sudden cardiac death. The death certificate did not list sudden cardiac death as the cause of death or as contributing to the cause of death. It was concluded in the autopsy report that the veteran died of arteriosclerosis of the coronary arteries. Another article remarked on a link between POW-related stressors and hypertension; however, the cause of death was not noted as being hypertension, and the record has not established that the veteran had arterial hypertension. Finally, the article indicating that stress can lead to hypertension and in turn to arteriosclerosis is too general and inconclusive to be of any significant probative value. It merely indicates a possible general link and does not indicate a more definite link between the veteran's PTSD and his arteriosclerotic heart disease. See Wallin, supra. For these reasons, the Board finds that the evidence is not so evenly balanced as to require application of the benefit of the doubt in favor of the appellant. Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). For these reasons and bases, the Board finds that a preponderance of the evidence of record establishes that the cause of the veteran's death is not related to military service, either directly or proximately. Entitlement to dependency and indemnity compensation (DIC) pursuant to the provisions of 38 U.S.C. A. § 1318 Criteria Benefits authorized by 38 U.S.C. § 1318 shall be paid to a deceased veteran's surviving spouse (see § 3.54(c)(2)) or children in the same manner as if the veteran's death is service connected when the following conditions are met: (1) The veteran's death was not caused by his or her own willful misconduct; and (2) The veteran was in receipt of or for any reason (including receipt of military retired or retirement pay or correction of a rating after the veteran's death based on clear and unmistakable error (CUE)) was not in receipt of but would have been entitled to receive compensation at the time of death for a service-connected disablement that either: (i) Was continuously rated totally disabling by a schedular or unemployability rating for a period of 10 or more years immediately preceding death; or (ii) Was continuously rated totally disabling by a schedular or unemployability rating from the date of the veteran's discharge or release from active duty for a period of not less than 5 years immediately preceding death. 38 C.F.R. § 3.22 (1999). The Court has held that a survivor of a deceased veteran is eligible for DIC under section 1318(b)(1) if (1) the veteran was in actual receipt of a 100% disability rating for the statutory period of time; (2) the veteran would have been in receipt of a 100% disability rating for such time but for CUE in a final rating or Board decision; or (3) if under specific and limited exceptions, the veteran was "hypothetically" entitled to a 100% disability rating for the required period of time. Marso v. West, No. 97-2178 (U.S. Vet. App., December 23, 1999). According to the Court, consideration of whether the veteran was "hypothetically" entitled to a 100% disability rating for the required period of time can only be made for claims where 38 C.F.R. § 19.196 applies, i.e., for those "entitled to receive" claims received prior to the March 1992 effective date of section 20.1106, or where a veteran had never filed a claim for VA benefits, and therefore no final VA decision regarding the veteran's level of disability was made. See Marso, supra (citing to Carpenter v. West, 11 Vet. App. 140 (1998) and Wingo v. West, 11 Vet. App. 307 (1998). Analysis The pertinent evidence of record shows that the veteran was discharged from active military duty in February 1967. In April 1994, the RO granted service connection for PTSD, assigning a 100 percent rating, effective June 14, 1991. The veteran died of arteriosclerotic coronary heart disease in November 1994. In this case, there is no contention that the veteran was 100 percent disabled from the date of his discharge from service and the record shows that the veteran was not rated as totally disabled from the date of discharge for a period of not less than five years immediately preceding his death. Nor does the appellant argue that any disability other than the veteran's PTSD warranted a 100 percent evaluation at any time during the veteran's lifetime. The veteran was in actual receipt of total compensation benefits (a 100 percent rating for his service-connected PTSD) effective from June 1991 until his death in November 1994, a period of less than 10 years. Thus, the veteran's PTSD was not rated as totally disabling for a period of 5 years following his discharge from service nor for a continuous period of 10 or more years immediately preceding his death. Therefore, entitlement cannot be granted because the veteran was not rated as totally disabled for the statutory period of time. See Marso, supra. In regards to CUE, the RO denied, in pertinent part, service connection for a nervous condition in May 1981. This decision became final. In April 1994, the RO granted service connection for PTSD, assigning a 100 percent rating, effective June 1991, the date of receipt of the veteran's claim of service connection for PTSD. The Board finds that the appellant has not alleged the kind of error that could be considered clear and unmistakable error. In fact, the record shows no indication that the appellant has specifically alleged that there was CUE in any final rating decision. The standard with respect to raising a claim for CUE is that it must be "the kind of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error." Fugo, 6 Vet. App. at 43. CUE requires more than a disagreement on how the facts are weighed or evaluated; the appellant must show that the correct facts, as they were known at the time, were not before the adjudicator or that pertinent regulatory or statutory provisions were incorrectly applied. See Russell v. Principi, 3 Vet. App. 310, 313 (1992). In order for a valid CUE claim to be raised, the appellant must allege with some specificity what the alleged error is, and, unless it is patently clear and unmistakable, the appellant must provide persuasive reasons as to why the result would have been manifestly different but for the alleged error. Bielby v. Brown, 7 Vet. App. 260, 269 (1994); Fugo v. Brown, 6 Vet. App. 40, 44 (1993); See Eddy v. Brown, 9 Vet. App. 52; 57 (1996). The Court has held that a claimant must raise with specificity issues of CUE under section 1318(b). See Marso, supra. The appellant has not alleged that there was CUE in any previous final rating decisions pertaining to the veteran. She has not alleged with any specificity that an error of law or fact was made in a final rating decision. As the appellant has not raised the issue of CUE in a final rating decision, the Board concludes that no further action or consideration is warranted as to this particular portion of the section 1318 analysis. The record shows that the appellant's claim for DIC benefits pursuant to 38 U.S.C.A. § 1318 was submitted after the effective date of 38 C.F.R. § 20.1106. The record also shows that there are previous final rating decisions denying service connection for a nervous condition and a final rating decision assigning a 100 percent disability rating for PTSD, effective June 14, 1991. Because the appellant filed her claim after the March 1992 effective date for section 20.1106, and the record shows that there are final VA decisions regarding the level of the veteran's psychiatric disability, the Board concludes that the analysis of whether the veteran was "hypothetically" entitled to a total or 100 percent disability rating for the required period of time is not for application as the limited exceptions provided in Carpenter and Wingo are not present in this particular case. See Marso, supra. As the criteria for a grant of entitlement to DIC benefits have not been satisfied, there is no entitlement and the appellant's claim fails because of absence of legal merit or lack of entitlement under the law, thereby warranting a denial of the claim as a matter of law. Sabonis v. Brown, 6 Vet. App. 426 (1994). ORDER Entitlement to service connection for the cause of the veteran's death is denied. Entitlement to DIC benefits pursuant to the provisions of 38 U.S.C.A. § 1318 is denied. RONALD R. BOSCH Member, Board of Veterans' Appeals