Veteranclaims’s Blog

August 27, 2013

Single Judge Application, DIC, 38 C.F.R. § 3.312(c)(3), Inadequate Medical Opinions

Excerpt from decision below:
“To the extent that the parties disagree whether the March 2010 VA examiner addressed this question, the Court agrees with the appellant that the examiner did not provide sufficient rationale for his opinion. Rather, the opinion contains a string of broad conclusory statements, such as the following: (1) The veteran’s “gastrointestinal disorder [was] completely unrelated to the cause of his death,” (2) “having a past duodenal ulcer and partial gastrectomy could [not] possibly cause a stroke over 40 years later,” and (3) “having had a part[] of his stomach removed does not increase the risk for atherosclerosis or stroke later in life.” R. at 143 (emphasis added).
Although a medical examiner is not required to provide a statement of reasons or bases supporting his determination or discuss all the evidence, see Acevedo v. Shinseki, 25 Vet.App. 286,293 (2012), he is required to support his findings with data and clear medical explanations connecting the two, see Nieves-Rodriguez and Stefl, both supra. Moreover, the fact that the veteran’s service-connected condition is not a risk factor for atherosclerosis or stroke and did not cause the stroke does not answer the question whether the service-connected condition caused “debilitating effects and general impairment of health to an extent that would [have] render[ed] the [veteran] materially less capable of resisting the effects” of the primary cause of death. 38 C.F.R. § 3.312(c)(3) (emphasis added).
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Based on the foregoing, the Court concludes that the Board relied on inadequate medical opinions and also provided an insufficient statement of reasons or bases for concluding that the veteran’s service-connected disabilities were not a contributory cause of death. See Allday and
Gilbert, both supra. The Board ignored § 3.312(c)(3) in its determination that the VA medical opinions were adequate to satisfy VA’s duty to assist, and in its overall determination denying the appellant’s claim for DIC benefits. See R. at 12-13. Accordingly, remand is necessary for the Board
(1) to address the applicability of § 3.312(c)(3), to include obtaining a medical opinion that adequately addresses whether the veteran’s service-connected gastrointestinal condition caused “debilitating effects and general impairment of health to an extent that would [have] render[ed] the
[veteran] materially less capable of resisting the effects” of the stroke, or to provide an adequate statement of reasons or bases explaining why such an opinion is unnecessary, and (2) to obtain an opinion addressing whether the veteran’s hypertension was aggravated by his service-connected
depressive neurosis.”
============================
Designated for electronic publication only
UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS
NO. 11-3864
MATTIE L. TAYLOR, APPELLANT,
V.
ERIC K. SHINSEKI,
SECRETARY OF VETERANS AFFAIRS, APPELLEE.
Before SCHOELEN, Judge.
MEMORANDUM DECISION
Note: Pursuant to U.S. Vet. App. R. 30(a),
this action may not be cited as precedent.
SCHOELEN, Judge: The appellant, Mattie L. Taylor, appeals through counsel a September
14, 2011, Board of Veterans’ Appeals (Board) decision that denied VA benefits for the cause of the
veteran’s death. Record of Proceedings (R.) at 3-14. This appeal is timely, and the Court has
jurisdiction to review the Board’s decision pursuant to 38 U.S.C. §§ 7252(a) and 7266(a). Both
parties filed briefs, and the appellant filed a reply brief. Single-judge disposition is appropriate. See
Frankel v. Derwinski, 1 Vet.App. 23, 25-26 (1990). For the following reasons, the Court will vacate
the Board decision and remand the matter for further proceedings consistent with this decision.
I. BACKGROUND
The appellant is the surviving spouse of the veteran, Arthur L. Taylor, who served honorably
on active duty in the U.S. Army from March 1944 to April 1946. R. at 905. In April 1946, the
veteran was granted disability compensation for a duodenal ulcer incurred during service. R. at 908-
11.
In October 1958, he underwent a partial gastrectomy and gastrojejunostomy, which resulted
in the removal of approximately 65% of his stomach. R. at 564, 716-18, 729. The veteran
subsequently reported weakness, nausea, and loose bowels, and was diagnosed with dumping
syndrome. R. at 573-80, 606, 669, 671, 686, 708. In a June 1977 statement, the veteran’s treating
physician reported that the veteran suffered from “severe dumping syndrome” and “spasms in the
stump of his stomach[,] which cause him pain and make him extremely nervous.” R. at 565.
At an August 1977 VA examination, the veteran reported that he was very nervous and
experienced daily stomach spasms. R. at 559-64. He was diagnosed with postgastrectomy dumping
syndrome with weakness, dizziness, sweating, palpitations, nausea, and vomiting. R. at 562. The
veteran also underwent a psychiatric examination in September 1997, which diagnosed
psychophysiological gastrointestinal reaction. R. at 563. The examiner commented that the
“veteran’s problem is primarily somatic in nature but [he] has definite additional neurotic traits as
well which do not reach the level where they would be considered a diagnosis separately,
nevertheless, may contribute to his gastrointestinal problem.” Id. In June 1978, the veteran’s
treating physician reported that the veteran became nauseated after meals (R. at 529), and in July
1978, the veteran described feeling nauseous every time he ate and when he was upset (R. at 522).
A June 1980 rating decision states that a Board of two psychiatrists opined that the veteran’s
“neuropsychiatric condition did cause his alcoholism and that he has an appreciable depression and
continued trouble with his gastrointestinal tract.” R. at 413. VA recharacterized his serviceconnected
duodenal ulcer as “depressive neurosis with anxiety, chronic, moderate with alcoholism
secondary to his neurosis and psychophysiological gastrointestinal reaction,” and separately awarded
disability compensation for organic brain syndrome, secondary to alcoholism. R. at 414.
In August 1985, the veteran stated that his indigestion and nervousness had gotten worse
with age, his memory was bad, he was depressed and confused. R. at 369-70. He also stated that
he had been in and out of the hospital for the past five to six years, was recently diagnosed with
cerebrovascular disease and transient ischemic attacks, and could not eat at times, which resulted
in nutrition problems and weight loss. Id.
The veteran died on August 6, 1988. R. at 339. His death certificate identifies the immediate
cause of death as a stroke due to, or as a consequence of, atherosclerosis, with hypertension listed
as a significant condition contributing to death. Id. The veteran’s hospital discharge summary listed
intracerebral hemorrhage as the principal diagnosis, and a “long history of alcohol dependency.”
R. at 266. At the time of the veteran’s death, he was service connected for depressive neurosis with
anxiety, chronic, moderate with alcoholism secondary to his neurosis and psychophysiological
2
gastrointestinal reaction, evaluated as 50% disabling, and organic brain syndrome, secondary to
alcoholism, evaluated as 10% disabling. R. at 343-44.
In November 2007, the appellant filed an application for dependency and indemnity
compensation. R. at 331-38. The appellant asserted that the veteran became sick every time he ate,
and that he began drinking alcohol to compensate for the pain that he suffered as a result of his
digestion problems. See R. at 293, 319, 338. An August 2008 rating decision, denied the appellant’s
claim. R. at 225-28.
The appellant filed a timely Notice of Disagreement stating that the veteran became anxious
and depressed as a result of his gastrointestinal illness, which lead him to drink to the point of
addiction. R. at 192-94. She asserted that the veteran’s drinking and anxiety attributed to his
development of hypertension, and that medical research suggests that excessive drinking and
alcoholism is known to cause atherosclerosis, strokes, and hypertension. R. at 194.
In a statement received by VA in September 2009, the appellant asserted that there is a direct
correlation between the veteran’s stroke and his service-connected disabilities because alcoholism
can affect cholesterol levels and hypertension, and the veteran’s hypertension was affected by the
stress he experienced as a result of his injury. R. at 174-75.
In November 2009, the VA regional office (RO) requested a medical opinion whether the
veteran’s service-connected disabilities were a contributory cause of death. R. at 168-69. The
request correctly listed the veteran’s service-connected disabilities at the time of his death and noted
that the death certificate identified the cause of death as “stroke due to atherosclerosis.” R. at 169.
The RO also defined contributory cause of death, as follows:
Contributory cause of death is inherently one not related to the principal cause. In
determining whether the service-connected disability contributed to death, it must
be shown that it 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.
Id.
In December 2009, a VA neurologist opined that “the events leading up to the actual
intracerebral bleed itself were more likely than not complications of hypertension and atherosclerotic
small vessel disease and in no way related to organic brain syndrome.” R. at 164-65. The examiner
3
also opined that the veteran’s “history of alcoholism is more likely than not unrelated to the
development of his hypertensive condition due to the lapse of at least 3-5 years between when he
significantly cut back or even abstained from alcohol use to when the first signs of hypertension
were documented.” R. at 166. In addition, the examiner stated that the veteran’s emphysematous
lungs strongly suggest a chronic smoking history, which is an “equipotent risk factor in the
development of hypertension in the general population,” and therefore, “any discussion regarding
the genesis of [the veteran’s] hypertensive state leading to his stroke would have to include smoking
or some similar form of pulmonary deteriorative inhaled toxin (i.e. secondary smoke exposure) into
consideration.” Id.
In January and February 2010, the RO requested additional VA medical opinions, which
included the same definition for contributory cause of death noted above, to address the veteran’s
psychiatric and gastrointestinal conditions and the cause of his death. R. at 157-59; see also R. at
144-46. In February 2010, a VA psychologist opined that alcohol was not a likely contributory
cause of death, and that there was “no scientific evidence to suggest a direct causal link” between
the veteran’s mental health disorders and stroke. R. at 150-51. In March 2010, a VA
gastroenterologist opined that the veteran’s “duodenal ulcer with subtotal gastrectomy was in no way
contributory to the cause of his death” – hemorrhagic stroke. R. at 143. The examiner stated:
Decades ago, duodenal ulcers were attributed to psychological stressors, hence the
term “psychophysiological GI reaction.” We now know that duodenal ulcers are
commonly caused by helicobacter pylori infections and [are] not related to
psychological stressor[s]. It is therefore unlikely that his GI disorders, namely
duodenal ulcers, were caused by any stressors in his life. In addition, having had a
part[] of his stomach removed does not increase the risk for atherosclerosis or stroke
later in life. His gastrointestinal disorder[s] were completely unrelated to the cause
of his death. There are no conceivable hypothes[e]s how having a past duodenal
ulcer and partial gastrectomy could possibly cause a stroke over 40 years later.
Id.
In a September 14, 2011, decision, the Board relied primarily on the December 2009 and
March 2010 VA opinions to deny the appellant’s claim for VA benefits for the cause of the veteran’s
death. R. at 3-14. This appeal followed.
4
II. ANALYSIS
Pursuant to 38 U.S.C. § 1310, DIC benefits are paid to a surviving spouse of a qualifying
veteran who died from a service-connected disability. See Dyment v. West, 13 Vet.App. 141 (1999),
aff’d sub nom. Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). A veteran’s death will be
considered service connected if the evidence demonstrates that a service-connected disability was
either the principal or a contributory cause of death. 38 C.F.R. § 3.312(a) (2013). A serviceconnected
disability is the principal cause of death when that disability, “singly or jointly with some
other condition, was the immediate or underlying cause of death, or was etiologically related” to the
death. 38 C.F.R. § 3.312(b). To be a contributory cause of death, the disability must have
“contributed substantially or materially” to death, “combined to cause death,” or “aided or lent
assistance to the production of death.” 38 C.F.R. § 3.312(c). “It is not sufficient to show that [a
service-connected disability] casually shared in producing death, but rather it must be shown that
there was a causal connection.” Id. Additionally,
[s]ervice-connected diseases or injuries involving vital organs should receive careful
consideration as a contributory cause of death, the primary cause being unrelated,
from the viewpoint of whether there were resulting debilitating effects and general
impairment of health to an extent that would render the person materially less
capable of resisting the effects of other disease or injury primarily causing death.
38 C.F.R. § 3.312(c)(3).
Although VA need not provide a medical examination in all cases, “once the Secretary
undertakes the effort to provide an examination when developing a service-connection claim, he
must provide an adequate one.” Barr v. Nicholson, 21 Vet.App. 303, 311 (2007). A medical
examination is considered adequate “where it is based upon consideration of the veteran’s prior
medical history and examinations and also describes the disability, if any, in sufficient detail so that
the Board’s ‘”evaluation of the claimed disability will be a fully informed one.”‘” Stefl v. Nicholson,
21 Vet.App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet.App. 405, 407 (1994) (quoting Green
v. Derwinski, 1 Vet.App. 121, 124 (1991))). Additionally, the opinion “must support its conclusion
with an analysis that the Board can consider and weigh against contrary opinions.” Id. at 124-25;
see also Nieves-Rodriguez v. Peake, 22 Vet.App. 295, 301 (2008) (noting that “a medical
examination report must contain not only clear conclusions with supporting data, but also a reasoned
medical explanation connecting the two”).
5
The Board’s determinations whether a service-connected disability is a principal or
contributory cause of death and whether a medical opinion is adequate are findings of fact, which
this Court reviews under the “clearly erroneous” standard. See D’Aries v. Peake, 22 Vet.App. 97,
104 (2008); Wray v. Brown, 7 Vet.App. 488, 492 (1995); see also Gilbert v. Derwinski, 1 Vet.App.
49, 52 (1990). A finding of fact is clearly erroneous when the Court, after reviewing the entire
evidence, “is left with the definite and firm conviction that a mistake has been committed.” United
States v. U.S. Gypsum Co., 333 U.S. 364, 395 (1948); see also Gilbert, 1 Vet.App. at 52.
As always, the Board must provide a statement of the reasons or bases for its determination,
adequate to enable an appellant to understand the precise basis for the Board’s decision as well as
to facilitate review in this Court. 38 U.S.C. § 7104(d)(1); see Allday v. Brown, 7 Vet.App. 517, 527
(1995); Gilbert, 1 Vet.App. at 56-57. To comply with this requirement, the Board must analyze the
credibility and probative value of the evidence, account for the evidence it finds persuasive or
unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the
claimant. Caluza v. Brown, 7 Vet.App. 498, 506 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir.
1996) (table).
In the decision here on appeal, the Board found that the veteran’s immediate cause of death
was “a stroke due to or as a consequence of atherosclerosis,” with hypertension as a significant
contributing condition. R. at 4. Relying on the December 2009 and March 2010 VA medical
opinions, the Board determined that the veteran’s service-connected moderate chronic depressive
neurosis with anxiety and alcoholism secondary to neurosis and a psychophysiological
gastrointestinal reaction and his service-connected organic brain syndrome secondary to alcoholism
did not cause or contribute materially or substantially to cause his death. R. at 5, 12-13.
The appellant argues that the Board erred by relying on inadequate medical opinions. She
asserts that the medical opinions are inadequate because (1) no examiner opined whether the
veteran’s service-connected mental disorder aggravated his hypertension such that hypertension
should be considered a service-connected cause of death, and (2) none of the opinions provided
information sufficient to permit the Board to apply 38 C.F.R. § 3.312(c)(3). Appellant’s Brief (Br.)
at 8-13; Reply Br. at 1-5. The Court will address each argument in turn.
First, the appellant contends that the record reasonably raised whether the veteran’s serviceconnected
mental disorder aggravated his hypertension, but none of the VA examiners offered an
6
opinion on this question. Appellant’s Br. at 11; see R. at 175 (stating that there is a direct correlation
between the veteran’s stroke and his service-connected conditions because the “stress” experienced
as a result of his “injury” effected his hypertension, which was a contributing condition to death);
194 (asserting that the veteran’s hypertension was exacerbated by his depressive neurosis with
anxiety). The Secretary does not dispute whether an examiner was required to address this question.
Rather, he argues that the December 2009 opinion addressed the contributory effects of the veteran’s
mental disorder, noting that the neurologist opined that the veteran’s organic brain syndrome was
less likely than not the cause or a contributory factor to the cause of death, and that his alcoholism
was unrelated to his development of hypertension. Id. at 9. Additionally, the Secretary avers that
the February 2010 psychologist reached the same conclusion as the neurologist, opining that
“alcohol was not a likely contributory cause and that there was no scientific evidence to suggest a
causal link between the [v]eteran’s mental health disorder and the stroke that resulted in his death.”
Id. at 10. The Secretary’s arguments are not persuasive.
Contrary to the Secretary’s argument, the December 2009 neurologist did not render an
opinion whether the veteran’s hypertension was aggravated by his mental disorder. See Reply Br.
at 1-2. Although the examiner opined that the veteran’s service-connected organic brain syndrome
was not a contributing factor to the veteran’s cause of death, the examiner explicitly disclaimed
having the expertise to opine whether the veteran’s neurosis with anxiety and psychophysiological
gastrointestinal reaction contributed to death. See R. at 164 (stating that “I cannot comment upon
[their role] since it is outside my realm of expertise”); see also R. at 9 (noting that the physician was
“unable to provide an opinion regarding the [v]eteran’s psychiatric and gastrointestinal problems”).
Similarly, the February 2010 psychologist’s opinion, that there was no “direct causal link” between
the veteran’s mental health disorders and stroke (R. at 151), does not equate to an opinion that the
veteran’s mental health did not aggravate his hypertension, a significant condition that contributed
to his death. The Secretary does not provide any medical support for his contention that “the lack
of connection between the stroke and mental health disorder supports the similar lack of relationship
between the [v]eteran’s mental health disorder and hypertension” (Secretary’s Br. at 10), nor is it an
inference that the Board drew from the examiner’s opinion. In fact, the Board did not address the
psychologist’s opinion in its decision.
7
The appellant also contends that the VA opinions are inadequate because no examiner
addressed whether the veteran’s symptoms of his partial gastrectomy rendered him less capable of
resisting the effects of the fatal atherosclerosis. Appellant’s Br. at 10-11. The appellant asserts that
the record shows that the veteran suffered from dumping syndrome, with nausea, dehydration,
weakness, and vomiting for nearly 30 years before his death (see R. at 369-70, 522, 529, 559-64,
565, 573-80, 594, 606, 669, 671, 686, 708), and therefore, reasonably raised whether the veteran’s
gastrointestinal symptoms caused malnutrition or other complications that affected his ability to
resist the effects of atherosclerosis. Appellant’s Br. at 10-11.
She explains that a further medical opinion is necessary because § 3.312(c)(3) requires the
Board to give careful consideration to service-connected diseases involving vital organs, including
“whether there were resulting debilitating effects and general impairment of health to an extent that
would [have] render[ed] the [veteran] materially less capable of resisting the effects of” the stroke
or atherosclerosis. 38 C.F.R. § 3.312(c)(3). Although the March 2010 gastroenterologist examiner
opined that “having had a part[] of his stomach removed does not increase the risk for
atherosclerosis or stroke later in life,” the appellant maintains that this statement is “most reasonably
read to convey an opinion regarding the actual physical removal of the stomach, rather than the
cumulative impact of decades of resulting symptoms.” Appellant’s Br. at 10 (quoting R. at 143).
Even assuming the statement could be construed to address the veteran’s ability to resist
atherosclerosis despite his digestive impairment, the appellant asserts that the opinion is inadequate
because the examiner failed to provide any supporting rationale for his opinion. Id.
In response, the Secretary contends that the March 2010 gastroenterologist opined that “there
is simply no medical connection between a partial gastrectomy and increased risk of atherosclerosis”
and that there was “‘no conceivable hypothesis’ connecting the [v]eteran’s gastrointestinal disorder,
duodenal ulcer[] and partial gastrectomy to the stroke which caused his death.” Secretary’s Br. at
10 (quoting R. at 143). Therefore, the Secretary argues that the examiner “did conclude . . . that the
[v]eteran’s partial gastrectomy did not render him less capable of resisting the fatal effects of
atherosclerosis.” Id. at 11. Additionally, the Secretary contends that there was no reason for the
Board to undergo an analysis of § 3.312(c)(3) because there was no evidence that the veteran’s
symptoms after the gastrectomy led to “major failure of a vital organ.” Id. at 12-13. The Court
disagrees.
8
Contrary to the Secretary’s suggestion, nothing in § 3.312(c)(3) requires “vital organ failure”
to trigger consideration under this subsection of the regulation. All that is necessary is that a
“[s]ervice-connected disease[] or injur[y] involve active processes affecting vital organs.” 38 C.F.R.
§ 3.312(c)(3). In the instant case, the Board identified § 3.312(c)(3) as part of its description of what
constitutes a contributory cause of death. R. at 7-8. However, the Court can find no evidence that
the Board considered and applied the regulation in the analysis portion of its decision. Given that
the Board identified the regulation as applicable to this case, it should have been considered and
discussed. See 38 U.S.C. § 7104(a); Schafrath v. Derwinski, 1 Vet.App. 589, 592-93 (1991) (the
Board is required to consider and discuss all applicable provisions of law and regulation where they
are made “potentially applicable through assertions and issues raised in the record”). The Board did
not discuss whether the veteran’s gastrointestinal disorder affected a vital organ, nor did it render
any findings whether the disorder caused debilitating effects and general impairment of health, and it must do so on remand.
To the extent that the parties disagree whether the March 2010 VA examiner addressed this question, the Court agrees with the appellant that the examiner did not provide sufficient rationale for his opinion. Rather, the opinion contains a string of broad conclusory statements, such as the following: (1) The veteran’s “gastrointestinal disorder [was] completely unrelated to the cause of his death,” (2) “having a past duodenal ulcer and partial gastrectomy could [not] possibly cause a stroke over 40 years later,” and (3) “having had a part[] of his stomach removed does not increase the risk for atherosclerosis or stroke later in life.” R. at 143 (emphasis added).
Although a medical examiner is not required to provide a statement of reasons or bases supporting his determination or discuss all the evidence, see Acevedo v. Shinseki, 25 Vet.App. 286,293 (2012), he is required to support his findings with data and clear medical explanations connecting the two, see Nieves-Rodriguez and Stefl, both supra. Moreover, the fact that the veteran’s service-connected condition is not a risk factor for atherosclerosis or stroke and did not cause the stroke does not answer the question whether the service-connected condition caused “debilitating effects and general impairment of health to an extent that would [have] render[ed] the [veteran] materially less capable of resisting the effects” of the primary cause of death. 38 C.F.R. § 3.312(c)(3) (emphasis added).
9

Based on the foregoing, the Court concludes that the Board relied on inadequate medical opinions and also provided an insufficient statement of reasons or bases for concluding that the veteran’s service-connected disabilities were not a contributory cause of death. See Allday and
Gilbert, both supra. The Board ignored § 3.312(c)(3) in its determination that the VA medical opinions were adequate to satisfy VA’s duty to assist, and in its overall determination denying the appellant’s claim for DIC benefits. See R. at 12-13. Accordingly, remand is necessary for the Board
(1) to address the applicability of § 3.312(c)(3), to include obtaining a medical opinion that adequately addresses whether the veteran’s service-connected gastrointestinal condition caused “debilitating effects and general impairment of health to an extent that would [have] render[ed] the
[veteran] materially less capable of resisting the effects” of the stroke, or to provide an adequate statement of reasons or bases explaining why such an opinion is unnecessary, and (2) to obtain an opinion addressing whether the veteran’s hypertension was aggravated by his service-connected
depressive neurosis.

Given this disposition, the Court will not at this time address the remaining arguments and
issues raised by the appellant. See Best v. Principi, 15 Vet.App. 18, 20 (2001). “A narrow decision
preserves for the appellant an opportunity to argue those claimed errors before the Board at the
readjudication, and, of course, before this Court in an appeal, should the Board rule against him.”
Id. In pursuing the matter on remand, the appellant is free to submit additional evidence and
argument on the remanded matter, and the Board is required to consider any such relevant evidence
and argument. See Kay v. Principi, 16 Vet.App. 529, 534 (2002) (stating that, on remand, the Board
must consider additional evidence and argument in assessing entitlement to benefit sought);
Kutscherousky v. West, 12 Vet.App. 369, 372-73 (1999) (per curiam order). The Court has held that
“[a] remand is meant to entail a critical examination of the justification for the decision.” Fletcher
v. Derwinski, 1 Vet.App. 394, 397 (1991). The Board must proceed expeditiously, in accordance
with 38 U.S.C. § 7112 (requiring Secretary to provide for “expeditious treatment” of claims
remanded by the Court).
10

III. CONCLUSION
After consideration of the appellant’s and the Secretary’s pleadings, and a review of the
record, the Board’s September 14, 2011, decision is VACATED and the matter is REMANDED for
further proceedings consistent with this decision.
DATED: August 26, 2013
Copies to:
Glenn R. Bergmann, Esq.
VA General Counsel (027)
11

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