Godwin v. DerwinskiGodwin v. Derwinski
Wallace B. Godwin served in the Army in World War II from November 12, 1942, to December 29, 1945. For approximately seven months, from September 1944 to late April 1945, he was held as a prisoner of war by the German Government. This appeal is from a March 19, 1990, Board of Veterans’ Appeals (BVA or Board) decision denying entitlement to service connection for residuals of an alleged left-shoulder injury and for bilateral defective hearing as well as an increased rating above 20-per-cent for peptic-ulcer disease. We rеmand the case for further proceedings at the Board with respect to the left-shoulder arthritis. As to the ulcer and hearing-loss issues, we find a failure on the part of the Department of Veterans Affairs to assist the claimant by requesting certain private and Army medical records which the veteran requested be sought and which he alleges would show information relevant to his respective claims. In the event that such records are located, the evidence should be evaluated on remand as to its sufficiency tо warrant reopening of the claim on each issue and, if found so sufficient, that claim should be readjudicated in accordance with this opinion. If no such records are located with respect to the claim, the Board’s decision with respect to that particular claim will stand affirmed.
I. BACKGROUND
At the veteran’s separation examination on November 28, 1945, no complaints or disabilities were noted. R. at 1. He first filed a claim with the Veterans’ Administration (now the Department of Veterans Affairs) (VA) in September 1978. He alleged а hearing loss due to noise from heavy bombing during an air raid while he was a prisoner of war in Germany and that he had received treatment in service in 1945 in Aberdeen, Maryland, for that condition. R. at 15-18. A report of an October 18, 1978, VA examination indicated “bilateral sensorineural hearing loss of moderate degree.” R. at 21. A VA Regional Office (RO) rating board decision denied service connection for hearing loss on December 19, 1978, stressing twice the absence of notation of hearing disability or complaints about hearing disability аt the time of the veteran’s separation. R. at 23.
In early 1980, the veteran sought to reopen his hearing loss claim and added a claim for an ulcer condition. In support of reopening, the veteran submitted lay state
In December 1981, after the veteran had sought again to reopen his claim in October of that year, he wаs given a POW protocol examination, which diagnosed anxiety neurosis with depressive features, bilateral deafness, osteoarthritis of the left shoulder and both hands shown by X-ray, and stomach problems with large hiatal hernia. R. at 35. A January 28, 1982, VARO rating board decision then granted a 10-percent rating for anxiety neurosis (pursuant to Pub.L. No. 97-37, 95 Stat. 935 (1980), which had established presumptive service connection for “any of the anxiety states” in an ex-POW of 30 or more days captivity (
On January 13,1987, the veteran’s representative requested to have the veteran’s arthritis considered under a new law enacted on October 28, 1986, which granted a rebuttable presumption of service connection for ex-POWs with “post-traumatic osteoarthritis”. Pub.L. 99-576, § 108, 100 Stat. 3248, 3252;
On November 30,1988, the veteran again sought to reopen the ulcer claim. R. at 111. The VARO rating board awarded him a 10-percent disability rating for “peptic ulcer disease” (R. at 118) for which a rebut-table presumption of service connection for ex-POWs had been established in Pub.L. 100-322,
In an April 21, 1989, response to the Statement of the Case of March 9, 1989, the veteran three times requested that the VA check Army medical records in connection with his assertion that he was on sick call with regard to a complaint about hearing while stationed for a week in Aberdeen, Maryland, at the end of his service. He also seemed to request that VA examine German Government medical records used at the Nürnberg war trials. R. at 131. He had also apparently requested in March 1989 that the RO obtain his military medical records. Supp.R. at 5. Although the record reflects that VA in December 1988 did request post-service medical records with regard to hospitalization, R. at 132-37 and Supp.R. at 1-4, there is no indication in the record that the military records were ever requested or that the veteran’s requests were ever acknowledged or responded to by VA, despite the veteran’s request to “please acknowledge.” R. at 131.
On May 23,1989, the veteran was afforded a VA examination with respect to peptic ulcer disease and an impression was noted of a “small sliding type of hiatal hernia that is self-reducible” (R. at 144), with a diagnosis of “рeptic ulcer disease by history.” R. at 145.
Thereafter, the veteran submitted a June 7, 1989, statement from Dr. Crotwell, a private physician, who, on the basis of X-rays, diagnosed “Severe traumatic arthritis OF THE LEFT SHOULDER WITH A FROZEN shoulder.” R. at 153. The veteran also submitted a June 6, 1989, letter from another private physician, Dr. Brock, who diagnosed “Severe sensory hearing loss bilaterally”. R. at 155. On June 20, 1989, the rating board issued a confirmatory decision with regard to the peptic-ulcer rating (R. at 157) and on August 4,1989, as to the left-shoulder arthritis (R. at 159). While acknowledging Dr. Crotwell’s diagnosis, the rating board found that “SC [Service connection] for arthritis of the left shoulder is not established.” R. at 159.
The veteran then submitted a September 1, 1989, letter from a third private physician, Dr. Butler, diagnosing “an active duodenal ulcer” warranting “an increase in compensation”. R. at 169.
On September 12, 1989, the veteran and his wife testified under oath before a VARO hearing officer. R. at 170-90. The hearing officer concluded that the veteran’s testimony with respect to the circumstances under which he had injured his left shoulder (falling approximately 20 feet while trying tо hide in order to avoid detection by German soldiers who then took him captive, R. at 171) and with respect to the hearing loss having resulted from his hiding in a large sewer pipe during an air raid while a prisoner (R. at 176-77) was not new and material so as to warrant a reopening of those claims. Based upon the hearing testimony and Dr. Butler’s statement, the hearing officer increased the veteran’s rating to 20 percent for his peptic ulcer. R. at 192-93.
The BVA’s March 19, 1990, decision confirmed the rating decisions of the hearing officer. As to the peptic ulcer, the BVA concluded that the severity was “no more than moderate with continuous moderate manifestations.” Wallace B. Godwin, BVA 90-10507, at 12 (Mar. 19, 1990). In confirming the 20-percent rating, the BVA noted that the “nonservice-connected disorder [of a hiatal hernia] has contributed to some degree to the veteran’s gastrointestinal symptomatology.... The evidence as a whole, in our judgment, shows that the actual manifestations of the veteran’s service-connected peptic ulcer disease are well encomрassed by the ... currently assigned” rating. Id. at 11.
As to the osteoarthritis of the left shoulder, the BVA stated that the history of left-shoulder injury “is not supported by contemporaneously recorded clinical data during service or at a time proximate thereto. The residuals of such a severe injury to the left shoulder, as was noted by history in a private physician’s recent statement [referring to Dr. Crotwell apparently], would have been clinically manifested at a time much earlier than is presently documented
As to hearing loss, the BVA stated: “The evidence received since [the 1983 BVA decision] does not include any contemporaneously recorded clinical documentation of chronic defective hearing during or at a time proximate to service.” Id. at 9. Again, the BVA concluded that “the evidence as a whole” does not support “a favorable determination in this matter.” Ibid.
A timely appeal to this Court followed under
The Secretary contends that “VA provided reasonable assistance to Mr. Godwin in the development and preparation of his claim” and gave his evidence proper and thorough consideration.” Br. at 14. As to the duty to assist, the Secretary stresses that
II. ANALYSIS
A. Hearing Loss
In order to justify the reopening of a claim, a VA claimant must submit “new and material evidence”.
In evaluating the evidence on a reopened claim, “under section [5108], ... the BVA [must] ... assess the new and material evidence in the context of the other evidence of record and make new factual determinations”. Jones, at 215. In concluding that the “evidence received since the time of the prior final appellate decision [BVA in 1983] does not ... [warrant] a favorable determination ... ”, Godwin, BVA 90-10507, at 9, the BVA applied the wrong standard in evaluating the hearing loss evidence. However, this is not prejudicial error under
Further as to the hearing-loss issue, we find that the Department failed in its obligation to assist the veteran in the development of the claim under
As to the appellant’s apparent request that VA search the Nürnberg trial medical evidence, the appellant was and still is entitled to a response from VA as to whether he has made a sufficient showing of the relevance of such records to his claim. The duty to assist is not unlimited. As quoted above,
Since this case is being remanded on the duty-to-assist issue as to the hearing-loss claim and, as discussed in part C, below, as
Under 38 U.S.C. 7104(d)(1) (formerly § 4004) and our precedents beginning with Gilbert v. Derwinski,
The appellant here has never been provided with a satisfactory explаnation by the RO or BVA as to why his and his wife’s sworn testimony and the six lay statements are not “sufficient evidence” of service connection of his hearing problem, especially why, under the “benefit of the doubt” rule in
B. Osteoarthritis
With rеspect to the left-shoulder arthritis issue, we conclude, first, that Dr. Crotwell’s diagnosis of “severe traumatic arthritis” after X-ray was new and material evidence sufficient to reopen that claim. The BVA seemed to reject Dr. Crotwell’s statement on the ground that the diagnosis of “traumatic” had not been made in the early 1980s when arthritis was first diagnosed in the veteran’s left shoulder. The Board stated: “The residuals of such a severe injury to the left shoulder ... would have been clinically manifested at a time much earlier than is presently documеnted by the medical evidence.” Godwin, BVA 90-10507 at 10. This is an example of what the Court found was impermissible refutation by the Board of “the expert medical conclusions in the record with [the BVA’s] own unsubstantiated medical con-
Furthermore, the Board’s analysis designed to show that the arthritic condition is not “attributable to any incident of service”, Godwin, BVA 90-10507, at 10, is irrelevant under the presumption established by
Hence, this issue must be remanded to the BVA for readjudication and, if the Board dоes not accept Dr. Crotwell’s diagnosis of post-traumatic osteoarthritis of the left shoulder, for the conduct of an examination of the veteran dealing specifically with that issue.
C. Ulcer
Although the BVA’s discussion of the ulcer issue does not appear to take into direct account Dr. Butler’s September 1989 letter, we find that to be harmless error. We so hold because the rating schedule with respect to a gastric ulcer requires that for a rating above 20 percent—the next higher rating is 40 percent—both “impairment of health manifested by anemia and weight loss or recurrent incapacitating episodes averaging ten days or more in duration at least four or more times a year” must exist.
There is, however, also a duty-to-assist issue as to the appellant’s ulcer claim. The appellant, twice in presenting his request for reopening in November 1988, once in his January 18, 1989, Notice of Disagreement (NOD), and again twice in his March 21, 1989, response to VA’s Statement of the Case, requested VA to obtain medical records of the treatment of his ulcer from the Columbia General Hospitаl in Andalusia, Arkansas. R. at 116, 121, 131. VA failed to respond to this request, as it should have. Because the appellant contended in his January 1989 NOD that his stomach condition was “much more severe than the VA has indicated” (R. at 121), he has adequately asserted how these records would be relevant to the question of the current severity of his ulcer disease for rating purposes. We, therefore, find that VA failed in its
III. CONCLUSION
Accordingly, as to the March 19, 1990, BVA decision, we retain jurisdiction and (1) on the issues of peptic ulcer disеase and of hearing loss, the decision and the record is remanded to the Board for the Secretary to comply, in accordance with this opinion, with the duty to assist and, if new and material evidence is found to have been produced thereby, for readjudication in accordance with this opinion; and (2) on the issue of the left-shoulder osteoarthritis, the matter is remanded for readjudication in accordance with this opinion. The Secretary shall file with the Clerk and serve upon the appellant a copy of the Board’s decision on remand. Within 14 days after such filing, the appellant shall notify the Clerk whether he desires to seek further review by the Court.
REMANDED.