Citation Nr: 0005870 Decision Date: 03/03/00 Archive Date: 03/14/00 DOCKET NO. 96-13 140 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to compensation benefits under 38 U.S.C.A. § 1151 for additional disability incurred as a result of injuries sustained during a Department of Veterans Affairs (VA) hospitalization from April 1 to 15, 1976, for purposes of accrued benefits. 2. Entitlement to service connection for the cause of the veteran's death. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The veteran had active service from September 1943 to February 1946. He died in November 1995, and the appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a regional office (RO) rating decision of July 1995, which denied the veteran's request to reopen his claim for compensation pursuant to 38 U.S.C.A. § 1151. He died in November 1995; however, the appellant expressed her desire to continue the veteran's claim, and subsequently perfected an appeal of the claim. In addition, the appellant appealed the September 1996 denial of her claim for entitlement to service connection for the cause of the veteran's death. A hearing was held on June 8, 1999, in Washington, D.C., before Jeff Martin, who is a member of the Board and was designated by the chairman to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 1991). FINDINGS OF FACT 1. There is no competent evidence demonstrating that the veteran had additional disability due to injuries sustained on April 6, 1976, while the veteran was hospitalized in a VA facility. 2. At the time of his death, service connection was in effect for trichophytosis of the feet and right hand, evaluated 30 percent disabling. 3. According to the death certificate, the veteran died in November 1995, at the age of 76 years, of a ruptured abdominal aortic aneurysm, due to or as a consequence of atherosclerosis. 4. There is no competent evidence that the aortic aneurysm or the atherosclerosis was of service onset or aggravation. 5. The veteran was not in receipt of a permanent and total service-connected disability rating at the time of his death, nor did he die of a service-connected disability. CONCLUSIONS OF LAW 1. The appellant has not submitted evidence of a well- grounded claim for compensation for additional disability incurred as a result of injuries sustained during a VA hospitalization from April 1 to 15, 1976, for purposes of accrued benefits. 38 U.S.C.A. § 5107 (1991). 2. The appellant has not submitted evidence of a well- grounded claim for service connection for the cause of the veteran's death. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Additional Disability Under 38 U.S.C.A. § 1151 A. Accrued benefits In July 1995, the RO denied the veteran's claim for compensation benefits under 38 U.S.C.A. § 1151 for additional disability incurred as a result of injuries sustained during a Department of Veterans Affairs (VA) hospitalization from April 1 to 15, 1976, on the basis that new and material evidence had not been submitted. The veteran died in November 1995; however, in a statement received in February 1996, the appellant indicated that she wanted to appeal that decision. Under VA laws and regulations, certain accrued benefits may be payable upon the death of a beneficiary. Except as otherwise provided, periodic monetary benefits to which a veteran was entitled at death under existing ratings or decisions, or those based upon evidence in the file at the date of death, and due and unpaid for a period not to exceed two years, shall, upon the death of such veteran, be paid to the veteran's surviving spouse. 38 U.S.C.A. § 5121 (West 1991 & Supp. 1999); 38 C.F.R. § 3.1000 (1999). Accordingly, the appeal as to that issue was developed, for accrued benefits purposes. B. De novo consideration Entitlement to compensation benefits under 38 U.S.C.A. § 1151 for additional disability incurred as a result of injuries sustained during a VA hospitalization from April 1 to 15, 1976, was previously denied by the Board in November 1988. Although in July 1995, the RO denied the veteran's claim on the basis that no new and material evidence had been submitted, in May 1996, the RO determined that there had been new and material evidence to reopen the claim, and denied the claim on the merits. In general, the Board has a legal duty to address the "new and material evidence" requirement regardless of the actions of the RO. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). However, in this case, part of the regulation relied upon in the previous decision was subsequently invalidated by the Court. See Gardner v. Derwinski, 1 Vet.App. 584 (1991), aff'd sub nom., Gardner v. Brown, 5 F.3d 1456 (Fed. Cir. 1993), aff'd sub nom., Brown v. Gardner, 115 S.Ct. 552 (1994). In this regard, in its November 1988 decision, the Board noted that neither additional disability nor negligence had been shown, and cited to 38 C.F.R. § 3.358(c)(3). However, in Gardner, the Court invalidated 38 C.F.R. § 3.358(c)(3), on the grounds that the element of fault required by the regulatory provision was beyond the scope of the authorizing statute, 38 U.S.C.A. § 1151 (formerly § 351). In March 1995, a new regulation was promulgated, in compliance with the Gardner dictates, which did not require negligence on the part of the VA for the veteran to prevail. (Although the statute itself was amended, effective in October 1997, to require negligence on the part of the VA, the veteran's claim was filed prior to that date, and is not affected by that amendment. See 38 U.S.C.A. § 1151 (West 1991 & Supp. 1997).) Since the Board's previous decision discussed the element of fault, the case must be considered on a de novo basis. C. Whether claim is well-grounded In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied, 524 U.S. 940 (1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, under 38 U.S.C. § 5107(a), the Department of Veterans Affairs (VA) has a duty to assist only those claimants who have established well grounded (i.e., plausible) claims. More recently, the United States Court of Appeals for Veterans Claims (Court or CAVC) issued a decision holding that VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). Accordingly, the threshold question that must be resolved in this appeal is whether the appellant has presented evidence that the claim is well grounded; that is, that the claim is plausible. The appellant contends that during a hospitalization in a VA facility from April 1 to 15, 1976, the veteran was attacked and beaten in the chest by another patient, which resulted in additional disability, including breathing difficulties, chest pain and swelling, and abnormalities shown on X-rays. Thus, the appellant's claim is premised on 38 U.S.C.A. § 1151. Because the claim was filed in April 1995, the version of § 1151 that is applicable to this case is the version that existed prior to its amendment in 1996, as those amendments were made applicable only to claims filed on or after October 1, 1997. See Pub. L. No. 104-204, § 422(b)(1), (c), 110 Stat. 2926-27 (1996). The pre-amendment version of § 1151 provides, in relevant part: Where any veteran shall have suffered an injury, or an aggravation of an injury, as the result of hospitalization, medical or surgical treatment, or the pursuit of a course of vocational rehabilitation under chapter 31 of this title, awarded under any of the laws administered by the Secretary, or as a result of having submitted to an examination under any such law, and not the result of such veteran's own willful misconduct, and such injury or aggravation results in additional disability to or the death of such veteran, disability or death compensation under this chapter and dependency and indemnity compensation under chapter 13 of this title shall be awarded in the same manner as if such disability, aggravation, or death were service-connected. 38 U.S.C.A. § 1151 (amended 1996). 1. Factual Background Records prior to the April hospitalization include hospital records pertaining to a VA hospitalization from April to May, 1972, which noted, inter alia, that a chest X-ray contained evidence of emphysema of the right upper lobe with scars to the right hilar area. The diagnosis was basilar artery insufficiency, probable, manifested by transient ischemic episodes, and hyperlipidemia, Frederickson Type IV. Outpatient treatment records show that in August 1973, he complained of some left sided chest pain, although in November 1973, he had no chest pain. Additionally, records from M. Lee, D.O., dated from December 1973 show that in May 1974, the veteran reported having fallen several times, with recent episodes of severe pain and dizziness. It was noted that he could not drive an automobile. The hospitalization at issue was precipitated by symptomatology shown on an outpatient visit of April 1, 1976, at which time the veteran complained of sharp pains in the right occipital region which radiated down the neck and to the top of the head. The previous day, he had had an episode of falling to the left with dizziness and disorientation, and he was admitted for a neurological work-up. Hospital records include progress notes, which report that on April 6, 1976, while the veteran was out in the hall in front of the nurse's station, another patient had become extremely agitated, and had grabbed the veteran's cane and struck him in the left clavicle area. He had also bitten his right index finger, but did not break the skin. The chest was slightly reddened, and the veteran became very weak, flushed, agitated and tremulous. Vital signs were taken and the veteran was put to bed. The doctor was contacted, and the veteran was possibly to have a chest X-ray. On April 11, 1976, the veteran stated that his left chest was still painful in the area where he had been hit with the cane. On April 13, 1976, he continued to complain of chest pain. He had an electrocardiogram scheduled. There was no swelling or discoloration present. He continued to be anxious about the incident in which he had been struck by the cane. On April 16, 1976, the veteran complained of occasional headache and neck pain, but he had not had dizzy spells or visual or equilibrium complaints. It was also noted that date that the nature of the veteran's illness and its probable relationship to an arteriosclerotic process had been explained to the veteran and his wife. Doctor's orders show the veteran's admission on April 1, 1976, with studies including chest and skull X-rays, electroencephalogram, echoencephalogram, and brain scan to be conducted. Medications ordered on admission included aspirin as needed for neck pain for seven days. On April 6, 1976, a chest X-ray was ordered, with the explanation that he had been beaten in the precordial area, and that bony lesions were to be ruled out. On April 8, 1976, aspirin as needed for head and neck ache for seven days was ordered. On April 15, 1976, the doctor's orders included aspirin for pain. X-rays reports showed that a chest X-ray report on April 1, 1976, noted that the cardiac shadow was normal in size. The left leaf of the diaphragm was slightly more elevated than the right. Some emphysematous changes were suspected in both upper lobes. X-rays of the left clavicle area on April 6, 1976, disclosed no evidence of fracture or dislocation. On April 12, 1976, an electrocardiogram was ordered, with the explanation that he had a history of basilar-vertebral insufficiency, and had occasionally complained of chest pain, but was clinically negative. The electrocardiogram disclosed non-specific S-T changes. The hospitalization summary contained the reports of all studies which had been planned on admission. The discharge diagnoses were basilar artery insufficiency, probable, with transient, intermittent ischemic episodes; hyperlipidemia, type IV; and mild, chronic depression. Evidence after the veteran's discharge from the hospital on April 15, 1976, includes the record of his visit to Dr. Lee on April 19, 1976, complaining of chest pain after having been struck across the chest by another patient while in the VA hospital. He reported that he had been struck in the left chest with his cane, and with a fist. He had been examined and X-rayed and informed that there were no fractures present. Dr. Lee's impression was that he had suffered a bruise to the chest wall with possible costochondral cartilage injury. On July 1, 1976, the veteran again saw Dr. Lee, complaining of congestion and tenderness in the chest. The chest was X-rayed with no evidence of fracture or changes since a previous examination. An artifact in the left chest was reported. Dr. Lee prescribed symptomatic medication. VA outpatient treatment records show that on August 3, 1976, the veteran complained of occipital headaches and "congestion" [quotes in original] in the upper left chest, plus pain, which had cleared in the past few days. This was noted to be the area of the contusion when he had been struck by another patient in April 1976. Physical examination of the lungs and heart were normal. Buffered aspirin for headaches was prescribed, and he was to have chest X-rays and an electrocardiogram. The electrocardiogram noted an injury to the left chest in April 1976, and hyperlipidemia; the graph was normal. The X-ray request noted a history of an injury to the left upper anterior chest, with discomfort since. The X-ray showed the cardiac shadow to be normal in size, with a slightly prominent aortic arch. The previously described minimal elevation of the left leaf of the diaphragm in relation to the right leaf of the diaphragm was again noted. The costophrenic angles were clear. There was no evidence of pleural effusion or pneumothorax. The trachea was in the midline. Minimal fibrotic changes were noted in both lungs, and the appearance of the chest was reported to be relatively unchanged since the examination of April 1, 1976. In November 1976, a VA outpatient treatment note discloses that the veteran complained of right temporal pains, numbness in the left extremities, and soreness and a dull ache in the left thorax, which was thought to actually suggest a cardiac pain, unrelated to exertion. Aspirin for headaches was again prescribed. In December 1976, the veteran had congestion of the lungs, with an episode of coughing up a small amount of blood. The veteran reported that he had noted a kernel in his left breast which had appeared and disappeared. Lungs were clear on physical examination. In January 1977, he saw Dr. Lee again, with the complaint of chest discomfort in the chest wall, slightly medial and superior to the nipple area. It was noted that inspection revealed a slight increase in the size of the left breast, over the right. A trial of Depo Medrol was given. The veteran returned in February 1977 with no improvement, and a trial of Mobidin tablets and Mobisyl cream to apply to the left chest was prescribed. Later that month, Dr. Lee's records noted that the veteran returned with no improvement, and had continued chest discomfort. The veteran was advised that he knew of nothing further to improve his complaint. In a letter written at the veteran's request in March 1977, Dr. Lee noted that on the February 25 visit, he "cold not demonstrate any evidence of injury, although the patient continues to complain of continuous and ongoing pain." He also wrote that he could "see no evidence of permanent damage, as a result of this 'attack'." It was his opinion that there was no tumor or cyst present, and he was surprised that the pain had not gradually improved, and felt that it should. He could not "deny the fact that the patient has had continued pain and discomfort over a prolonged period of time due to this trauma to the chest." In March 1977, the veteran was seen at the VA, complaining of headache and dizzy spells, as well as a burning sensation in the left precordium of the chest. Cardiac examination was normal. In June 1977, he complained of continued headaches and dizzy spells, and he continued to be treated for these complaints during the succeeding months. In September 1977, the chest, heart and lungs were noted to be normal on examination. VA records show the veteran 's hospitalization from December 1977 to January 1978 for evaluation of worsening of his electroencephalogram and lipid profile. In addition, he complained of worsening of his headaches and numbness of the left side. His discharge diagnoses were vertebral-basilar insufficiency and type IV hyperlipidemia. The veteran was hospitalized in private facilities from February to March 1978 complaining of shortness of breath. He had had no previous episodes of this problem. History was noted to be significant for a 40 pack year smoking history. Physical examination was unremarkable except for an increased chest diameter. There were wheezes and rales on examination. Chest X-rays revealed no interval changes since April 28, 1976. A repeat X-ray revealed no gross lesion throughout the pulmonary fields, but there were some prominent bronchovascular markings. Another repeat X-ray revealed prominent interstitial markings in both lower lungs with no remarkable interval change. An electrocardiogram revealed sinus tachycardia. Due to continued shortness of breath, he was transferred to another private hospital. The admission note for this hospitalization reported a history of dyspnea, although a week earlier, he had developed chest pain as well as dyspnea. He had a history of vascular insufficiency to the brain, but no history of cardiac failure in the past. The final diagnosis was chronic obstructive pulmonary disease. Subsequent records show the veteran's continued treatment for chronic obstructive pulmonary disease, with an asthmatic component, which became increasingly severe during the succeeding years. According to a Memorandum dated in August 1977 by a VA neurologist, the veteran had been struck by his cane by another patient in April 1976. The nurse had observed a reddened area below the left clavicle immediately after the incident; no abnormalities other than this contusion were disclosed, including on X-ray and electrocardiogram. It was noted that the left breast area had never been swollen, and had only showed a reddening at the onset and a superficial cutaneous bruise mark or ecchymosis within the few days after the injury. On the personal examination of August 3, 1976, there was no abnormality in the area of the injury to suggest swelling or other deviation from normal of the left chest, breath or heart. He concluded that there was no evidence that the veteran experienced anything other than a minor, superficial contusion of the skin just below the left clavicle, and there was no indication that he sustained any permanent damage. The file also contains an affidavit signed by the veteran in January 1980, in which he detailed his recollections of the injury on April 6, 1976, and subsequent symptoms and treatment. Regarding the initial injury, he noted that the assailant had struck him twice with the handle of the cane in the left chest, just to the right of the nipple area, and then given him a "karate chop" in the same area . After his assailant was restrained, he went to the waiting room, where his wife and other patients noted that the veteran appeared "strange." The veteran recalled that he had been given aspirin after this incident, and eight aspirins a day for the remainder of the time he was in the hospital; nevertheless, his chest pain continued. He stated that a complete body scan planned had been canceled after the beating. After his discharge, he stated, he went to see a private doctor, Dr. Lee, about the pain he was having from the beating. On June 3, 1976, he had been seen at the VA for follow-up, and advised to continue taking the aspirin to present clotting in his chest and to ease the chest pain. He returned to Dr. Lee on July 1, who ordered X-rays, and showed him an area on the chest that he could not explain. He prescribed medication for the chest congestion. The veteran stated that on August 3, 1976, he was seen at the VA, at which time he felt that the doctor made some inconsistent statements, such as noting that X-rays had shown no abnormalities, but pointing to the area of the veteran's chest where he was beaten. The veteran stated that in his November 1976 appointment, the doctor admitted he had swelling in his chest, and probable pain, but felt it would get better. He stated that in December 1976, he complained of chest congestion and spitting up blood, and was told that there was no problem and that the swelling and pain would improve. In January 1977, he stated that he saw Dr. Lee again, who gave him a shot of Cortisone, and thought that the swelling was infected cartilage. Upon his return, in February 1977, he stated that Dr. Lee felt that the swelling was worse, and later that month, he told the veteran that he knew that the veteran was having a lot of pain with the amount of swelling in the chest. The veteran noted that in March 1977, he was seen at the VA, but the doctor still would not admit to any injury to the veteran's chest. In September 1977, the veteran stated, he was evaluated by the VA for his head and neck disability. The doctor examined the chest where he had been beaten, and although he surely must have noted the swelling, discoloration and pain, he only stated that he did not think that there was permanent damage. At her hearing before the undersigned in June 1999, the appellant testified regarding her recollections of the events in question, which, except for some chronological discrepancies which may be attributed to the period of time that has elapsed since the incident, essentially corroborates the veteran's 1980 affidavit, as well as numerous subsequent statements. 2. Analysis Under 38 U.S.C.A. § 5107(a), all claimants seeking compensation, including those seeking compensation under section 1151, have the initial burden of showing that their claim is well grounded. Jimison v. West, 13 Vet. App. 75 (1999). For a claim to be well grounded under the pre- amendment version of 38 U.S.C.A. § 1151, the appellant must provide: (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of incurrence or aggravation of an injury as the result of hospitalization; and (3) medical evidence of a nexus between that asserted injury or disease and the current disability. Jones v. West, 12 Vet. App. 460 (1999). It must be emphasized that where the determinative issue involves medical causation or etiology, or a medical diagnosis, competent medical evidence to the effect that the claim is "plausible" or "possible" is required. Epps, 126 F.3d at 1468. Further, in determining whether a claim is well-grounded, the supporting evidence is presumed to be true and is not subject to weighing. King v. Brown, 5 Vet.App. 19, 21 (1993). However, regarding medical conditions, a layperson is only competent to provide testimony regarding an "observable condition." Falzone v. Brown, 8 Vet.App. 398 (1995). Thus, while the statements made in the veteran's affidavit and other documents, as well as the appellant's written statements and hearing testimony, are presumed to be true, in order to be considered, the statements must relate to observable conditions. Moreover, a layperson is not competent to relate what a doctor has said. Robinette v. Brown, 8 Vet.App. 69 (1995) ("the connection between the layman's account, filtered as it was through a layman's sensibilities, of what a doctor purportedly said is simply too attenuated and inherently unreliable to constitute 'medical' evidence"). In determining whether additional disability exists, the veteran's physical condition immediately prior to the disease or injury on which the claim for compensation is based will be compared with the subsequent physical condition resulting from the disease or injury. 38 C.F.R. § 3.358(b). As noted above, the medical evidence prior to the April 1976 hospitalization included an incident of chest pain, and chest X-ray evidence of emphysema of the right upper lobe with scars to the right hilar area. On admission, the chest X-ray showed that the left leaf of the diaphragm was slightly more elevated than the right, and emphysematous changes were suspected in both upper lobes. During the hospitalization, he was indeed struck in the chest by another patient. For purposes of determining whether the claim is well-grounded, the veteran's version of the injury must be accepted, which was that he was struck twice with the cane and once with the hand, in a "karate chop." Thus, injury is shown. Additionally, it is undisputed that this injury resulted in a contusion and bruising. Regarding whether the veteran had additional disability resulting from that incident, he claimed that he suffered from chest pain, swelling and difficulty breathing subsequent to the injury, which did not resolve. However, chest pain, alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, No. 97-1948 (U.S. Vet. App. Dec. 29, 1999). Moreover, while the veteran and the appellant are competent to describe physical symptoms such as swelling and breathing difficulties, in order to be attributed to the injury, there must be medical evidence of a nexus between the described symptoms and a disability. See Voerth v. West, 13 Vet.App. 117 (1999). In this case, the medical evidence does not confirm the presence of a disability attributed to the injury. In this regard, although Dr. Lee's initial impression on seeing the veteran in April 1976 was that he had suffered a bruise to the chest wall with possible costochondral cartilage injury, in July 1976, Dr. Lee noted that the chest was X-rayed with no evidence of fracture or changes since a previous examination. An artifact in the left chest was reported. Additionally, in January 1977, Dr. Lee noted that inspection revealed a slight increase in the size of the left breast, over the right, and the veteran showed no subsequent improvement in February 1977. However, in March 1977, Dr. Lee noted that on the February 25 visit, he "could not demonstrate any evidence of injury, although the patient continues to complain of continuous and ongoing pain." Although he could not "deny the fact that the patient has had continued pain and discomfort over a prolonged period of time due to this trauma to the chest," he also wrote that he could "see no evidence of permanent damage, as a result of this 'attack'." Although statements from doctors which are inconclusive as to disease origin do not supply the nexus requirement of a well- grounded claim, "the use of cautious language does not always express inconclusiveness in a doctor's opinion on etiology, and such language is not always too speculative for purposes of finding a claim well-grounded." Lee v. Brown, 10 Vet. App. 336, 339 (1997). Such an opinion must be viewed in its full context. Id. In context, Dr. Lee's opinion, while initially suspecting a possible costochondral cartilage injury, ultimately concluded that he could see no evidence of permanent damage due to the attack, notwithstanding the veteran's continued complaints of pain. Moreover, at no time did Dr. Lee explicitly attribute the "slight increase in size of the left breast over the right" or the "artifact" shown on X-ray to the injury. Consequently, Dr. Lee's opinion does not provide medical evidence of additional disability, due to the assault. The remainder of the medical evidence also fails to attribute additional disability to the injury. Chest pain and congestion shown in November and December, 1976, were not attributed to the injury, and shortness of breath which precipitated the hospitalizations in February and March, 1978, was diagnosed as chronic obstructive pulmonary disease. However, the significant history reported at that time was a smoking history, and emphysematous changes in the lungs had been demonstrated on X-rays prior to the injury. More importantly, there is no medical evidence of record suggesting that chronic obstructive pulmonary disease was causally related to the assault in April 1976. Similarly, the medical evidence does not indicate that any other chronic disability was causally related to the injury. Thus, while the Board recognizes the appellant's sincere belief that her husband's subsequent chest difficulties, including chronic obstructive pulmonary disease, resulted from the injury during his hospitalization in April 1976, in the absence of medical evidence supporting this contention, the claim is not well-grounded. II. Entitlement to service connection for the cause of the veteran's death. As indicated above, in order for a claim to be well grounded, there must be (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in- service injury or disease and the current disability. Epps, 126 F.3d at 1468; Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). For service connection for the cause of death of a veteran, the first requirement, evidence of a current disability, will always have been met (the current disability being the condition that caused the veteran to die). Ramey v. Brown, 9 Vet. App. 40, 46 (1996). For the remaining elements, there must be competent evidence that disability that caused or contributed to death was incurred or aggravated in service, and of a nexus between the two, or competent evidence of a nexus between the veteran's cause of death and a service-connected disability. Ruiz v. Gober, 10 Vet.App. 352 (1997). According to the death certificate, the veteran died in November 1995, at the age of 76 years. The cause of death was noted to be a ruptured abdominal aortic aneurysm, with an interval of "minutes" between onset and death, due to or as a consequence of atherosclerosis, with an interval of "years" between onset and death. An autopsy was not performed. A. Service incurrence Service medical records do not contain any mention of atherosclerosis or aortic aneurysm. Postservice medical records show that a VA hospitalization from April to May, 1972, resulted in diagnoses of basilar artery insufficiency, probable, manifested by transient ischemic episodes, and hyperlipidemia, Frederickson Type IV. Subsequent outpatient treatment records show that he was treated with a low cholesterol, anti-atherosclerotic diet for his hyperlipidemia. Thus, atherosclerosis was first manifested many years after the veteran's discharge from service, and there is no evidence of a nexus between the cause of death, and any disease or injury incurred in service. Moreover, there is no medical evidence of an etiological connection between the veteran's service-connected trichophytosis of the feet and right hand, and his death, or any disability that contributed to cause his death. Additionally, the veteran was not in receipt of a permanent and total service-connected disability rating at the time of his death. Accordingly, the claim is not well-grounded. B. Death due to disability resulting from VA hospitalization, under 38 U.S.C.A. § 1151 The appellant contends that the injuries sustained during the beating in April 1976, while the veteran was hospitalized in a VA facility, contributed to cause his death. It is asserted that the veteran did not have symptoms such as chest pain and breathing difficulties prior to that injury, but that he experienced such symptoms after the injury, until his death. Thus, this aspect of the claim must also be considered, pursuant to 38 U.S.C.A. § 1151. For the issue to be well-grounded, there must be medical evidence, or in certain circumstances lay evidence, of incurrence or aggravation of an injury as the result of hospitalization; and medical evidence of a nexus between that asserted injury or disease and the disability that resulted in the veteran's death. See Jones, Ramey, supra. The appellant contends that during a hospitalization in a VA facility from April 1 to 15, 1976, the veteran was attacked and beaten in the chest by another patient, and there is ample evidence, including the hospital records and an affidavit from the veteran, signed in 1980, that the veteran was struck in the chest with a cane and by the hand of another patient in the hospital. Thus, there was injury. Regarding a nexus between this injury and a disability that caused the veteran's death, as discussed above, there is no competent evidence that the injury resulted in additional disability. The appellant contends that an aneurysm may result from trauma, but the medical evidence of record does not suggest that the ruptured abdominal aortic aneurysm that was the immediate cause of the veteran's death was due to trauma, or specifically due to trauma incurred during the VA hospitalization in April 1976. The appellant, as a layperson, is not competent to provide an opinion as to a causal connection, nor is she competent to relate what a doctor said. See Robinette, supra. Similarly, there is no medical evidence attributing the veteran's atherosclerosis to the injury. Although the appellant contends that the veteran did not have any pertinent symptoms until after the injury, the additional disability must be shown to be actually the result of the injury, and not merely coincidental therewith. 38 C.F.R. § 3.358(c)(1). Consequently, in the absence of medical evidence of a nexus between the cause of the veteran's death and injuries sustained during a VA hospitalization in April 1976, the claim is not well- grounded. ORDER Entitlement to compensation benefits under 38 U.S.C.A. § 1151 for additional disability incurred as a result of injuries sustained during a Department of Veterans Affairs (VA) hospitalization from April 1 to 15, 1976, for purposes of accrued benefits, is denied. Entitlement to service connection for the cause of the veteran's death is denied. JEFF MARTIN Member, Board of Veterans' Appeals