Citation Nr: 0000618 Decision Date: 01/07/00 Archive Date: 01/11/00 DOCKET NO. 96-00 149A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an evaluation in excess of 20 percent for urticaria, from September 21, 1990 to January 11, 1998. 2. Entitlement to an evaluation in excess of 40 percent for urticaria, from January 12, 1998. 3. Whether new and material evidence has been presented to reopen a claim of entitlement to service connection for headaches. 4. Entitlement to service connection for side effects due to medication taken for service-connected urticaria, including headaches and chest tightness. 5. Entitlement to service connection for sinusitis. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A. Hinton, Associate Counsel INTRODUCTION The veteran served on active duty from December 1982 to November 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida (RO), which denied the benefits sought on appeal. In April 1995, the Board of Veterans' Appeals (Board) granted service connection for urticaria. In a May 1995 rating decision, the RO assigned a 10 percent disability rating for the service-connected urticaria, effective from September 21, 1990. The veteran filed a notice of disagreement in July 1995 with respect to the assigned 10 percent rating. In a rating decision of August 1995, the RO increased the evaluation assigned for the urticaria to 20 percent, effective from September 21, 1990. The veteran filed a notice of disagreement in August 1995 with respect to the 20 percent rating. The RO provided the veteran and his representative a statement of the case in January 1996, which noted that a notice of disagreement was received in August 1995. Later in January 1996, the RO received a substantive appeal from the veteran, who asserted that he should be entitled to a disability rating higher than that currently in effect for the service-connected urticaria. In March 1997, the RO proposed that the 20 percent rating be reduced to 10 percent. That month the veteran disagreed with the proposed reduction. In a rating decision of June 1997, the RO decreased the evaluation assigned for the service-connected urticaria from 20 percent to 10 percent, effective from September 1, 1997. The RO provided the veteran a supplemental statement of the case in June 1997. In September 1997, the veteran's representative argued, in effect, that a disability rating higher than 20 percent should be assigned to the service-connected urticaria. In November 1997, the Board remanded the case to the RO for further development with respect to the veteran's rating claims associated with his service-connected urticaria. In a June 1999 rating decision, the RO assigned the service- connected urticaria an evaluation of 20 percent, effective from September 1, 1997; and 40 percent evaluation, effective from January 12, 1998. However, as the veteran is presumed to seek the maximum benefit available, that action does not abrogate the appeal as to the increased rating issues. See AB v. Derwinski, 6 Vet. App. 35, 38 (1994). The June 1999 rating decision also denied claims of entitlement to service connection for sinusitis, and for side effects due to medication taken for service-connected urticaria. Finally, that rating decision denied the veteran's application to reopen his claim of entitlement to service connection for headaches. The veteran appealed that rating decision as to these denied claims. In view of the foregoing, the Board determines that the issues on appeal are as noted on the title page. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. During the period from September 21, 1990 to January 11, 1998, the veteran's urticaria was manifested by mild symptoms involving periodic hives associated with exposure to heat and emotions, and lasting from a few minutes to a few hours. 3. During the period from January 12, 1998, the veteran's urticaria was manifested by severe symptoms involving periodic hives associated with exposure to heat and emotions, and lasting from a few minutes to a few hours. 4. Service connection for headaches was previously denied by the RO and confirmed by the Board in a decision issued in October 1995. 5. The evidence added to the record since the October 1995 Board decision denying service connection for headaches is not wholly cumulative and, when considered in connection with evidence previously assembled, is so significant that it must be considered in order to fairly decide the merits of the service connection claim. 6. There is no competent medical evidence of a nexus between the claimed headaches disorder and the veteran's period of active military service or some incident thereof. 7. There is no competent medical evidence of a nexus between the claimed side effects of medication taken for urticaria and that medication. 8. There is no competent medical evidence of a nexus between the claimed sinusitis disorder and the veteran's period of active military service or some incident thereof. CONCLUSIONS OF LAWS 1. A rating in excess of 20 percent for urticaria is not warranted during the period from September 21, 1990 to January 11, 1998. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. § 3.321(b)(1), 4.104, Diagnostic Code 7118 (1999). 2. A rating in excess of 40 percent for urticaria is not warranted during the period from January 12, 1998. 38 U.S.C.A. §§ 1155, 5107(b) (West 1991); 38 C.F.R. § 3.321(b)(1), 4.104, Diagnostic Code 7118 (1999). 3. Evidence added to the record since the October 1995 Board decision, which denied service connection for headaches, is new and material, and the claim for that benefit is reopened. 38 U.S.C.A. § 5107, 5108(a) (West 1991); 38 C.F.R. § 3.156(a) (1999). 4. The veteran's claim of entitlement to service connection for headaches is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.102, 3.303 (1999). 5. The veteran's claim of entitlement to service connection for side effects due to medication taken for service- connected urticaria, including headaches and chest tightness, is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.102, 3.303 (1999). 6. The veteran's claim of entitlement to service connection for sinusitis is not well-grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.102, 3.303 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background Service medical records show that during a September 1982 enlistment examination, the veteran reported no complaints referable to any currently claimed disorders on appeal. After examination at that time, the clinical evaluation was normal for all systems relevant to this appeal. The veteran was seen periodically in 1985 for complaints of dizziness, which was sometimes associated with complaints of headaches. A May 1985 clinical record shows that when the veteran was seen with complaints of dizziness with forward bending. An X-ray report that day for sinus examination noted no significant abnormalities. The veteran was seen in July 1985 with complaints of dizziness and headaches for three to four month. No diagnosis was made at that time. During an August 1985 examination, the veteran reported complaints of ear, nose or throat trouble and shortness of breath. He reported no complaints referable to headaches or sinusitis. After examination, the evaluation was normal for relevant systems. The veteran was seen in August 1985 for an internal medicine consultation, and complained of dizziness and headaches. A service seperation examination is not of record. During a VA general medical examination in September 1992, the veteran gave a history of recurrent welts, rashes, and sometimes itching, which was precipitated by exposure to sunlight and heat. He complained of sensation of pins and needles in the skin, followed by welts. Regarding the respiratory system, the veteran reported that during service he had complaints of shortness of breath when arising, which was accompanied by dizziness and headaches, and was aggravated by sunlight. The veteran complained of occasional headaches. The September 1992 VA examination report noted that the veteran presently had no active dermatosis, and the skin was found to be normal on examination. On examination, the evaluation was normal for head, face and neck; nose, sinuses, mouth and throat; and cardiovascular system. Neurological examination showed normal sensory motor status, and normal coordination, reflexes and equilibrium. The report contains diagnoses of history of angioedema; subjective shortness of breath by history; and headaches of unknown etiology. Related chest X-ray and spirometry examinations were normal. A June 1995 VA neurological examination report recorded complaints of headaches for the previous 10 years, which were related to emotional stress or when the veteran was hot. After examination, the assessment was that the veteran most likely had muscle tension headaches, as there was no neurological evidence of other pathology, and the headaches were unlike migrainous headaches. During a February 1997 VA vascular examination, the veteran complained of breaking out in hives, which occurred for no apparent reason and would come and go at most any time. The symptoms usually occurred once a day, lasting a few minutes to two hours. He also would break-out during a hot shower or during emotional changes. The report noted that the veteran did not have vascular problems; and did not have dermographia, or respond to pressure on the skin. On examination of the skin, there were no nervous manifestations, no disfiguring manifestations, and no skin disorder manifest during the present examination. On vascular examination, skin appearance, and pulsations in the upper and lower extremities were all normal. The report contains a diagnosis of mild chronic urticaria. During a March 1998 VA vascular examination, the veteran complained of attacks of angioneurotic edema approximately four times per day, which include swelling of his arms, legs, abdomen, chest, throat, and tongue. He reported that his most recent serious attack was three days before the examination, when he had to go to the emergency room to be treated with epinephrine injection secondary to laryngeal edema. His attacks were precipitated by various factors, particularly emotion and sunlight. The veteran reported no symptoms of aortic aneurysm, no previous surgical therapy for aneurysms, occlusive disease, or varicose veins. The veteran reported occasional paresthesias and abnormal sensations of tingling. The report noted that there was no evidence of claudication or ischemic rest pain, and no evidence of cold sensitivity. The examiner noted that photos documented the peau d'orange swelling of all extremities and gluteal region, due to the angioneurotic edema. The examiner opined that the angioneurotic edema obviously had a severe effect on the veteran's usual daily activities and occupation, and noted that the veteran frequently had his job interrupted by the attacks. On examination, there was no evidence of renal, cardiac, or carotid bruits. Cardiac status was within normal limits. No evidence was found of abdominal aortic aneurysm, superficial phlebitis, ulceration or tissue loss. The report noted that on testing, the skin was warm. The report noted that the veteran showed some mild edema of the thighs, which was constant, and was kind of like a peau d'orange edema. Color was normal and without scars. The veteran had no eczema or tenderness. The report noted that there were no attacks of blanching or flushing with the angioneurotic edema in the extremities, but that the veteran did feel flush in the face. There was no evidence of erythromelalgia or of varicosities. The report contains a diagnosis of severe angioneurotic edema. The claims file contains VA and private medical records showing treatment for various disorders, in the 1990's through May 1999. II. Analysis A. Increased Ratings for Urticaria When a claimant is awarded service connection for a disability and subsequently appeals the RO's initial assignment of a rating for that disability, the claim continues to be well grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). Accordingly, the Board finds that the veteran's claims for increased ratings are well grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.102 (1999). The Board is also satisfied that all relevant facts have been properly and sufficiently developed to address the issues at hand. In accordance with 38 C.F.R. §§ 4.1, 4.2 (1999) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the veteran's service medical records and all other evidence of record pertaining to the history of the service-connected urticaria. The Board has found nothing in the historical record which would lead it to conclude that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of the remote clinical histories and findings pertaining to the disability for which entitlement to an increased evaluation is currently considered on appeal. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (1999). The Board attempts to determine the extent to which the veteran's service-connected disabilities adversely affect his ability to function under the ordinary conditions of daily life, and the assigned ratings are based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 4.1, 4.10 (1999). Separate diagnostic codes identify the various disabilities. If there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). The Board notes that the veteran filed his initial notice of disagreement with respect to the May 1995 rating decision, which assigned the initial rating following the April 1995 Board decision's initial award of service connection. In looking at the subsequent procedural history of this case, the Board determines that the veteran's present appeal arises from that May 1995 rating decision. In this situation, the rule from Francisco v. Brown, 7 Vet. App. 55, 58 (1994) ("Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance."), is not applicable. Rather, at the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The veteran's urticaria is evaluated at a 20 percent level, effective from September 21, 1990 to January 11, 1998; and 40 percent, from January 12, 1998. The veteran's urticaria disability has been rated by analogy to angioneurotic edema under 38 C.F.R. § 4.104, Diagnostic Code 7118. At the time of the initial May 1995 rating decision, the veteran's service-connected urticaria was rated under 38 C.F.R. § 4.119, Diagnostic Code 7806, which pertains to the skin disorder eczema. Subsequently, beginning with the August 1995 rating decision, the veteran's urticaria has been rated under Diagnostic Code 7118, which pertains to angioneurotic edema, and which the Board finds is more appropriate given the nature of the veteran's urticaria disability. Effective January 12, 1998, the Schedule for Rating Disabilities for the cardio-vascular system, to include angioneurotic edema, was revised. The United States Court of Appeals for Veterans Claims (Court) has held that where a law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version most favorable to the appellant should apply unless Congress provided otherwise or permitted the Secretary to do otherwise. Karnas v. Derwinski, 1 Vet. App. 308 (1991). In Rhodan v. West, 12 Vet. App. 55 (1998), the Court observed that when the Secretary adopts a revised rating schedule and publishes it in the Federal Register, with a clearly stated an effective date, the effective date rule contained in 38 U.S.C. § 5110(g), prevents the application of it to a claim prior to the effective date. Therefore, the revised rating schedule cannot be applied to the period prior to January 12, 1998. Under Diagnostic Code 7118, prior to January 12, 1998, a 20 percent evaluation is assignable for moderate; frequent attacks of moderate extent and duration. A 40 percent evaluation may be assigned for angioneurotic edema which is severe; frequent attacks with severe manifestations and prolonged duration. Under the new rating criteria, a 20 percent rating is warranted if there are attacks without laryngeal involvement lasting one to seven days and occurring five to eight times a year, or; attacks with laryngeal involvement of any duration occurring once or twice a year. A 40 percent rating is warranted where there are attacks without laryngeal involvement lasting one to seven days or longer and occurring more than eight times a year, or; attacks with laryngeal involvement of any duration occurring more than twice a year. 1. Rating From September 21, 1990 to January 11, 1998 Looking first at the 20 percent evaluation in effect prior to January 12, 1998, the Board notes that the revised criteria of Diagnostic Code 7118 could not provide a basis for an increased rating prior to January 12, 1998, since that is also the effective date of the changes to the rating schedule. Rhodan v. West, 12 Vet. App. 55 (1998). On review of the record prior to January 1998, VA clinical records show that the veteran was first seen for episodes of "sweating under the skin" in July 1991. At that time, no examination findings were recorded but the report contains an impression of chronic skin problem. A September 1992 VA examination report described the veteran's skin condition and cardiovascular system as normal. The diagnosis indicated only a history of angioedema and subjective shortness of breath by history. Subsequent private medical records in 1992 and 1993 show that the veteran was seen periodically for complaints of hives related to heat and emotional conditions or activity. None of these records contain any objective findings of a severe condition, with frequent attacks with severe manifestations and prolonged duration, such as to warrant an evaluation in excess of 20 percent. The Board notes that in a July 1995 VA progress note, a VA examiner recorded an assessment of chronic severe urticaria, episodic. However, that record shows that on examination the veteran's skin was noted to be normal. The subsequent record prior to January 12, 1998 shows that the veteran's skin disability was generally under control with medication. The objective clinical evidence during the period from the effective date of service connection through January 11, 1998 does not indicate that he had any severe attacks during that period. During his February 1997 VA examination, although he complained of daily outbreaks of hives, no relevant abnormalities were found and the diagnosis was mild chronic urticaria. The veteran's attacks had also not been shown to be of prolonged duration. On his February 1997 VA examination, the veteran reported that his symptoms subsided within a few minutes to two hours. In sum, VA clinical records prior to January 12, 1998 fail to show evidence demonstrating frequent attacks with severe manifestations and prolonged duration. Thus, a rating in excess of 20 percent under the relevant previous criteria is not warranted. 2. Rating From January 12, 1998 The Board notes that both the old and new criteria may be applied with respect to the evaluation since January 12, 1998. However, the Board notes that the veteran is already assigned a 40 percent evaluation since January 12, 1998, which is the maximum assignable evaluation under both the previous and current criteria of Diagnostic Code 7118. There is no evidence of erythromelalgia, varicosities, phlebitis, or other manifestations to warrant an increase under any other related schedular criteria. See § 4.104, Diagnostic Codes 7119, 7120, 7121. The Board has also considered possible entitlement to an extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b) (1999), for both periods of time before and since December 12, 1998. However, the record has not presented evidence of such an exceptional or unusual disability picture, with related factors including frequent hospitalizations or marked interference with employment beyond that contemplated by the assigned evaluations, as to render impractical the application of the regular schedular standards. Moreover, the veteran has reported that he had had no periods when he was incapable of working at his job due to the disability. Accordingly, the Board finds that the RO did not err in failing to refer these claims to the Director of the Compensation and Pension Service for an initial determination. See Floyd v. Brown, 9 Vet. App. 88, 95 (1996). B. New and Material Evidence The veteran claims that he has provided new and material evidence to reopen his claim of entitlement to service connection for a headaches disorder. Prior to the June 1999 rating decision from which this appeal arose, service connection for headaches was last denied by the Board in an October 1995 decision, which is final as to that claim based on the evidence then of record. See 38 U.S.C.A. § 7105(c) (West 1991); 38 C.F.R. §§ 3.104(a), 20.302, 20.1103 (1999). However, a claim will be reopened if new and material evidence has been submitted since the last final disallowance of the claim on any basis. 38 U.S.C.A. § 5108; 38 C.F.R. §§ 3.156(a), 20.1105 (1999); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Smith v. West, 12 Vet. App. 312, 214 (1999). If new and material evidence is presented or secured with respect to a claim that has been disallowed, VA must reopen the claim and review its former disposition. 38 U.S.C.A. § 5108. In this regard, the Board must perform a three-step analysis when a veteran seeks to reopen a claim based on new evidence. Winters v. West, 12 Vet. App. 203, 206 (1999) (en banc). See Hodge v. West, 155 F.3d 1356, 1362 (Fed. Cir. 1998) (overruling the test set forth in Colvin v. Derwinski, 1 Vet. App. 171 (1991), which stated that "new" evidence was "material" if it raised a reasonable possibility that, when viewed in the context of all the evidence, the outcome of the claim would change); Elkins v. West, 12 Vet. App. 209, 213 (1999) (en banc) (stating that, after Hodge, new and material evidence may be presented to reopen a claim, even though the claim is ultimately not well grounded). First, the Board must determine whether the evidence is new and material. Winters, 12 Vet. App. at 206. According to VA regulation, "new and material evidence" means 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 that it must be considered in order to fairly decide the merits of the claim. 38 C.F.R. § 3.156(a). This definition "emphasizes the importance of the complete record for evaluation of the veteran's claim." Hodge, 155 F.3d at 1363. In determining whether evidence is "new and material," the credibility of the new evidence must be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992); but see Duran v. Brown, 7 Vet. App. 216, 220 (1994) ("Justus does not require the Secretary to consider the patently incredible to be credible"). Second, if the Board determines that new and material evidence has been produced, the case is reopened. Immediately upon reopening the case the Board must determine whether, based on all the evidence of record, the reopened claim is well-grounded pursuant to 38 U.S.C.A. § 5107(a). Winters, at 206. Finally, if the claim is well-grounded, the Board may proceed to evaluate the merits of the claim after ensuring that VA's duty to assist has been fulfilled. Id. Evidence that was of record at the time of the prior Board decision in October 1995 included the veteran's service personnel and medical records, private and VA clinical and examination records, and various statements from the veteran. The evidence added since October 1995 includes records of later private and VA treatment, the reports of VA examinations in February 1997 and March 1998, and various statements by the veteran. In the October 1995 Board decision, the Board had determined that the evidence showed that the veteran was diagnosed solely with muscle tension headaches, which was not a disability and not due to any other disorder. Indeed the June 1995 VA examination report contains an assessment of muscle tension headaches, and noted that there was no evidence neurologically of any other pathology. The examiner noted that the character of the headaches were unlike migrainous headaches. On the basis of the available evidence at that time, the October 1995 Board decision determined that the headaches symptomatology was not a present disability due to disease or injury, and therefore the claim was not well grounded. The evidence received since the October 1995 Board decision includes a May 1997 VA clinical note that contains an assessment of headaches, for which a migraine etiology could not be excluded. VA clinical notes in June and July 1997 also contain assessments indicating that symptoms suggested a migraine etiology. Subsequent VA treatment notes in September 1997 and later contain assessments of migraine headaches, and also address the question of etiology. The evidence received since October 1995 includes VA and private clinical records not previously of record, which address pertinent issues as to the presence and etiology of the veteran's claimed headaches. The clinical records not previously of record, contain evidence that bears directly and substantially on the issue of whether the veteran has a current headaches disorder linked to service. This evidence is not wholly cumulative or redundant and provides a more complete picture as to the etiology of the veteran's claimed headaches disorder. Elkins v. West, 12 Vet. App. 209, 214 (1999). As such, the new evidence is sufficiently significant to the issue in this case that it must be considered in order to fairly decide the merits of the claim. The additional evidence is therefore new and material, and the claim must be reopened and considered based on all the evidence of record. See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110 (West 1991); 38 C.F.R. § 3.303(a). Service connection requires a finding that there is a current disability that has a definite relationship with an injury or disease or some other manifestation of the disability during service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establish that the disorder was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). However, as discussed above, immediately upon reopening a claim, the Board must determine whether, based on all the evidence of record, the reopened claim is well-grounded pursuant to 38 U.S.C.A. § 5107(a). Winters, at 206. A well- grounded claim is plausible, meritorious on its own, or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Moreau v. Brown, 9 Vet. App. 389, 393 (1996). For purposes of determining whether a claim is well-grounded, the Board presumes the truthfulness of the supporting evidence. Robinette v. Brown, 8 Vet. App. 69, 77-78 (1995); King v. Brown, 5 Vet. App. 19, 21 (1993). In order for a claim to be well-grounded, there must be competent evidence of a current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the in-service injury or disease and the current disability (medical evidence). Epps v. Gober, 126 F.3d 1464, 1468 (1997); Caluza, 7 Vet. App. 498, 504 (1995). Where the determinative issue involves a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). In this case, the Board finds that the claim for service connection for headaches is not well-grounded. There is no competent medical evidence of record that provided a nexus between the claimed headaches disorder and the veteran's period of active service or any incident therein. While the service medical records show several complaints of headaches, there is no finding of any chronic headaches disorder during service. Particularly, there is no evidence of migraine headaches during service or until many years after service in May 1997. Moreover, the veteran has offered no medical evidence to show a causal relationship between his currently diagnosed migraine headaches and his service or any service-connected disability. The veteran asserts that VA clinical records show a relationship between his migraine headaches and his service-connected urticaria, alternatively as a direct cause or by way of a side effect of medication taken for the urticaria. However, the clinical records of April and May 1997, which he refers to in his June 1999 notice of disagreement, do not contain any opinion as to the etiology of the veteran's headaches. The April 1997 clinical note referred to by the veteran merely relates the veteran's subjective complaints that constant headaches were a side affect of medication taken for urticaria. No opinion is given there or in any other medical record that the veteran's headaches are caused by the medication. The May 1997 VA clinical note that the veteran refers to contains an assessment of "headaches, cannot exclude migraine etiology." A subsequent VA clinical note in June 1997 contains an assessment noting that the veteran received relief from his headaches with Depakote, which the examiner noted to suggest that the etiology was migrainous. However, none of the competent medical evidence of record shows that the veteran's migraine headaches are related to service or a service-connected disability. Thus, the claim is not plausible and, therefore, not well-grounded. Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). C. Service Connection for Side Effects Due to Medication Taken for Service-Connected Urticaria The veteran has alleged that he developed side effects due to medication taken for his service-connected urticaria, which include headaches and chest tightness. As discussed more fully above, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110 (West 1991); 38 C.F.R. § 3.303(a). Service connection may be granted on a secondary basis for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (1999). In order for a claim of entitlement to service connection to be well- grounded, there must be competent evidence of a current disability (a medical diagnosis); of incurrence or aggravation of a disease or injury in service (lay or medical evidence); and of a nexus between the in-service injury or disease and the current disability (medical evidence). Epps v. Gober, 126 F.3d 1464, 1468 (1997); Caluza, 7 Vet. App. 498, 504 (1995). In this case, the Board finds that the claim for service connection for side effects due to medication taken for his service-connected urticaria, including headaches and chest tightness is not well-grounded. There is no competent medical evidence of record that provided a nexus between the claimed side effects and medication taken the veteran's for his service-connected urticaria. In a September 1997 statement, the veteran alleged that he developed side effects from medication taken to prevent urticaria and migraine headache, Zyrtec and Depakote. He noted side effects from these drugs, including extreme drowsiness, dizziness, vision change, chest pain, and severe depression. However, the clinical record does not contain any findings or opinion that relates these medications to any chronic pathology manifest by these claimed symptoms. The Board notes that in his October 1999 substantive appeal, the veteran alleged that Zyrtec resulted in constant headaches and chest tightness. He referred to an April 1997 VA clinical note, which he asserts noted that the Zyrtec had side effects of constant headaches and chest tightness. Review of that record shows, however, that the examiner merely recorded the veteran's subjective complaints, and belief, that the medication resulted in constant headaches and chest tightness. The examiner, however, made no such finding or opinion that could be construed as relating any headaches or chest tightness to the Zyrtec or any other medication taken for a service-connected disability. While the record shows that the veteran received relief from headaches with Depakote, as shown in an assessment contained in a June 1997 VA clinical note, the record does not contain any evidence of an etiological relationship between the veteran's headaches and that medication. On review of the clinical record, none of the competent medical evidence of record shows that any claimed side effects are related to medication taken for any service- connected disability. Thus, the claim is not plausible and, therefore, not well-grounded. Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). D. Service Connection for Sinusitis The veteran has alleged that he developed chronic sinusitis during service. In this case, the Board finds that the claim for service connection for sinusitis is not well-grounded. There is no competent medical evidence of record that provided a nexus between the claimed sinusitis disorder and the veteran's period of active service or any incident therein. In this regard, the Board notes that the medical evidence includes service medical records, private and VA clinical and examination reports, as well as statements from the veteran. In claiming entitlement to service connection for sinusitis the veteran has noted that sinusitis was assessed during service, and that he was seen subsequently for sinusitis in 1997. However, he has offered no medical evidence to show a causal relationship between any currently diagnosed sinusitis and his service or any service-connected disability. Service medical records do show that the veteran was seen in May 1985 when the assessment was sinusitis. However, associated X-ray examination was normal, and there is no subsequent evidence of any further sinusitis symptomatology during service. Post-service, during VA examination in September 1992, examination of the sinuses was normal. The first evidence of any sinusitis disorder is found in a July 1997 VA progress note, when the veteran complained of frequent mucous draining. At that time, examination of the head, eyes, ears, nose and throat was normal, and the examiner indicated an assessment of very questionable sinusitis. When the veteran was seen in April 1999 for complaints of sinus drainage and dry cough symptoms, the assessment was sinusitis. However, none of the competent medical evidence of record since service shows that the veteran's sinusitis is related to service. Thus, the claim is not plausible and, therefore, not well-grounded. Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). E. Conclusion The Board has considered the veteran's entitlement to service connection for headaches; for side effects due to medication taken for his service-connected urticaria, including headaches and chest tightness; and for sinusitis. However, none of the competent medical evidence of record shows that any of these claimed disorders is related to service. Thus, the claims are not plausible and, therefore, not well-grounded. Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). If the veteran were to rely solely on his own assertions that these claimed disorders are related to service or medication taken for service related disability, his own lay opinion would be insufficient evidence to support the claim. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (holding that lay persons are not competent to offer medical opinions). Under these circumstances, the Board finds that the veteran has not submitted well-grounded claims for service connection for headaches; for side effects due to medication taken for his service-connected urticaria, including headaches and chest tightness; or for sinusitis. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.102; Epps, 126 F.3d at 1468. Therefore, the duty to assist is not triggered and VA has no obligation to further develop the veteran's claim. Morton v. West, 12 Vet. App. 477 (1999); Epps, 126 F.3d at 1469; Grivois v. Brown, 5 Vet. App. 136, 140 (1994). ORDER An evaluation in excess of 20 percent for urticaria, from September 21, 1990 to January 11, 1998, is denied. An evaluation in excess of 40 percent for urticaria, from January 12, 1998, is denied. Service connection for headaches is denied. Service connection for side effects due to medication taken for service-connected urticaria, including headaches and chest tightness, is denied. Service connection for sinusitis is denied. ROBERT E. SULLIVAN Member, Board of Veterans' Appeals