Citation Nr: 1213550	
Decision Date: 04/13/12    Archive Date: 04/26/12

DOCKET NO.  07-35 700	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Petersburg, Florida


THE ISSUE

Entitlement to service connection for hepatitis C.


REPRESENTATION

Veteran represented by:	The American Legion


ATTORNEY FOR THE BOARD

S. Becker, Associate Counsel



INTRODUCTION

The Veteran served on active duty from February 1974 to November 1974.  This included foreign service in Germany.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida.  Service connection for hepatitis C was denied therein.  An appeal as to this determination subsequently was perfected by the Veteran.  


FINDING OF FACT

The weight of the evidence does not show that the Veteran's hepatitis C is related to his service.


CONCLUSION OF LAW

The criteria for establishing service connection for hepatitis C have not been met.  38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2011).


REASONS AND BASES FOR FINDING AND CONCLUSION

I.  Duties to Notify and Assist

Before addressing the merits, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits as provided for by the Veterans Claims Assistance Act (VCAA) of 2000.  38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a).

Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide.  38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability).  Dingess v. Nicholson, 19 Vet. App. 473 (2006).  Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included.  Id.

The Veteran was notified by letter dated in August 2006 of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence.  This letter also included information on how VA determines disability ratings and effective dates when service connection is granted.

The Veteran was notified via letter dated in May 2007 of the criteria for establishing service connection specifically for hepatitis C.  In addition, he once again was supplied with information on how VA determines disability ratings and effective dates when service connection is granted.

Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required.  None is found by the Board.  See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007).  Indeed, the above shows that VA's duty to notify has been more than satisfied.  The August 2006 letter predated the initial adjudication by the RO, who in this case is the AOJ, in November 2006.  All notice elements were addressed therein.  Nothing more was required.  As such, the May 2007 letter which provided more specific information tailored to the Veteran's claim with respect to one of these elements and reiterated some of the other elements was unnecessary.

Pursuant to the duty to assist, VA is required to aid the claimant in the procurement of service treatment records and other pertinent treatment records, whether or not they are in Federal custody, as well as provide a medical examination and/or obtain a medical opinion when necessary.  38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159, 3.326(a).

VA has obtained the Veteran's service treatment records.  Private treatment records from the one treatment provider identified by him also have been obtained.  No VA treatment records have been obtained.  The duty to assist is not applicable in this regard, however, as the Veteran has not identified any such records.  See 38 U.S.C.A. § 5103A(b)(1).  

VA requested the Veteran's Social Security Administration (SSA) records.  A response was received that these records, with the exception of an irrelevant summary of earnings which has been associated with the claims, had been destroyed.  They accordingly were formally found to be unavailable, and the Veteran was informed that a decision would be made without them.  See 38 U.S.C.A. § 5103A(b)(2); 38 C.F.R. § 3.159(e)(1).

A VA medical examination was afforded to the Veteran in May 2009.  The examiner reviewed the claims file, interviewed the Veteran regarding his pertinent history, conducted a physical assessment, and obtained applicable diagnostic tests.  Thereafter, the VA examiner rendered an opinion as to service etiology.  All of the above actions finally were documented by this examiner in an examination report.  A Veteran's Health Administration (VHA) expert opinion regarding etiology additionally was rendered in December 2011 in response to the Board's request for such.  The VHA expert did so after reviewing the claims file.  As the VA medical examination and VHA expert opinion answer all questions necessary to decide this matter, the Board finds them adequate.  See Barr v. Nicholson, 21 Vet. App. 303 (2007) (defining adequacy with respect to medical examinations and opinions as those providing sufficient detail so that the Board can perform a fully informed evaluation of the claim).  

Significantly, neither the Veteran nor his representative has identified any particular additional development necessary for a fair adjudication of the claim that has not been undertaken.  The record also does not indicate any such development.  Therefore, the Board finds that VA's duty to assist has been satisfied.  Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio, 16 Vet. App. at 183.

As both the duty to notify and the duty to assist have been fulfilled, appellate review may proceed without prejudice to the Veteran.  See Bernard v. Brown, 4 Vet. App. 384 (1993).

II.  Service Connection

The Veteran seeks service connection for hepatitis C.  He contends that this disability is a result of either transporting Vietnam Veterans, sharing razors, sharing drinks, piercing his ear, or receiving multiple injections from an air compressor gun during service.

Service connection "basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service . . . or if preexisting such service, was aggravated therein."  38 C.F.R. § 3.303(a); see also 38 U.S.C.A. § 1110.

Service connection is presumed when there is no record of a disease during service if certain circumstances exist.  38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309.  Applicable here are those for presumptive service connection for chronic diseases.  38 U.S.C.A. § 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a).  First, the Veteran must have served 90 days or more of active service during a period of war or after December 31, 1946.  38 U.S.C.A. § 1112(a); 38 C.F.R. § 3.307(a)(1).  Second, the Veteran must have manifested a chronic disease such as cirrhosis of the liver to a compensable degree within one year from the date of separation from service.  38 U.S.C.A. § 1101(3), 1112(a)(1); 38 C.F.R. §§ 3.307(a)(2), (3), 3.309(a).  Affirmative evidence rebutting in-service incurrence or aggravation of the disease must be taken into consideration even if the two aforementioned circumstances are met.  38 U.S.C.A. §§ 1113, 1153; 38 C.F.R. §§ 3.307(d), 3.309(a).

To establish direct service connection rather than presumptive service connection, there generally must be (1) medical or satisfactory lay evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical or satisfactory lay evidence of a nexus between the current disability and the in-service disease or injury.  See Hickson v. West, 12 Vet. App. 247 (1999); Barr, 21 Vet. App. at 303.

Direct service connection also may be established if the evidence of record reveals chronicity or continuity.  38 C.F.R. § 3.303(b).  If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes.  Id.; see also Barr, 21 Vet. App. at 303.  Continuity of symptomatology post-service is required where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity legitimately may be questioned.  Id.; see also Savage v. Gober, 10 Vet. App. 488 (1997).  

Further, direct service connection may be established for any disease initially diagnosed after discharge when the evidence establishes that it was incurred in service.  38 C.F.R. § 3.303(d).

Several risk factors for hepatitis C have been recognized.  These include:  transfusion of blood or blood product before 1992, organ transplant before 1992, hemodialysis, tattoos, body piercing, intravenous drug use (from shared instruments), high-risk sexual activity, intranasal cocaine (from shared instruments), accidental exposure to blood products as a health care worker, combat medic, or corpsman by percutaneous (through the skin) exposure or mucous membrane exposure, and other direct percutaneous exposure to blood such as by acupuncture with non-sterile needles or the sharing of toothbrushes or shaving razors.  VA Training Letter 01-02 (April 17, 2001); VA Training Letter 98-110 (November 30, 1998).

The following key points regarding the contraction of hepatitis C also have been recognized.  First, hepatitis C is spread primarily by contact with blood and blood products.  Second, the highest prevalence of hepatitis C infection thus is among those with repeated, direct percutaneous exposure to blood (i.e., intravenous drug users, recipients of blood transfusions before screening of the blood supply began in 1992, and hemophiliacs treated with clotting factor before 1987).  Third, hepatitis C can potentially be transmitted with the reuse of needles for tattoos, body piercing, and acupuncture.  VA Fast Letter 04-13 (June 29, 2004).

As such, VA has concluded that the large majority of hepatitis C infections can be accounted for by known modes of transmission, primarily transfusion of blood products before 1992 and injection drug use.  Yet VA also has recognized that transmission of hepatitis C via airgun injectors is "biologically plausible."  Id.

The Board must assess the probative value of all the evidence, including medical evidence.  The weight of evidence may be discounted "in the light of its own inherent characteristics and its relationship to other items of evidence."  Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997).  However, the Board must account for evidence which it finds to be persuasive or unpersuasive and provide reasons for rejecting any material evidence favorable to the Veteran.  See Gabrielson v. Brown, 7 Vet. App. 36 (1994), Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt is given to the Veteran.  38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert, 1 Vet. App. at 49.  As such, the Veteran prevails when the evidence supports his claim or is in relative equipoise but does not prevail when the preponderance of the evidence is against the claim.  Id.

Although all the evidence has been reviewed, only the most salient and relevant evidence is discussed herein.  See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence).  

Service personnel records reflect that the Veteran was a grenadier/infantryman.

Service treatment records reveal that the Veteran received several inoculations.  They also reveal that he was treated for gonorrhea in August 1974.  However, these records do not reveal that the Veteran complained of, sought treatment for, or was diagnosed with hepatitis C or cirrhosis of the liver.  No abnormalities were found in this regard upon clinical evaluation at his November 1974 separation examination.  It was noted at that time that he had no recurrent problems with respect to gonorrhea.  Also noted was "drug abuse, heroin."

Private treatment records dated in July 2006 reflect a diagnosis of hepatitis C.  They further reflect that the Veteran had a history of intravenous drug use.  Finally, these records reflect that he underwent a liver biopsy.  Cirrhosis was found.  

The Veteran recounted his in-service hepatitis C risk factors in an October 2006 statement.  He indicated that he transported Vietnam Veterans.  He then indicated that he did not remember whether or not he had ever shared a razor during service but that there was a great possibility he had.  Next, he indicated sharing drinks and getting his ear pierced during service.  He finally indicated that no other risk factors apply to him.

In his April 2007 notice of disagreement, the Veteran additionally raised the risk factor of receiving multiple air compressed injections during service.  He indicated that the gun was not cleaned between uses.

The Veteran reported at his May 2009 VA medical examination that he quit drinking alcohol three to four years prior and that he has had five to six sexual partners in his lifetime.  He denied ever having any piercings, tattoos, blood transfusions, or hemodialysis as well as ever having taken cocaine intranasally.  With respect to hepatitis C, he reported being diagnosed approximately 30 years after service and last having treatment three years prior because he lost his insurance coverage.  

Cirrhosis of the liver and chronic hepatitis C were diagnosed by the VA examiner following physical assessment and diagnostic testing.  The examiner then noted that the Veteran had several risk factors for cirrhosis.  It additionally was noted that alcohol abuse and heroin use were his greatest known risk factors for hepatitis C.  The VA examiner next conceded that it was within the realm of possibility that airgun inoculation caused the Veteran's hepatitis C.  However, the examiner indicated that this was less likely as not given that this theory of transmission is unproven.  The VA examiner finally opined that it could not be said, without resorting to mere speculation, when the Veteran contracted hepatitis C.  Yet the examiner noted that it was unlikely he contracted it during service given that he spent only nine months out of his 36 years of adult life there.

In a June 2009 statement, the Veteran noted that he has never used intravenous drugs.

The VHA expert indicated in December 2011 that risk factors for hepatitis C include intravenous drug use, blood transfusion before 1992, and multiple sexual partners/high risk sexual activity.  Then, this expert noted that the Veteran has a history of gonorrhea, a sexually transmitted disease.  Also noted was that his history of drug use is unclear, given the service treatment records documenting a history of heroin use but his denial of drug use in 2009.  The VHA expert presumed that the former was more reliable.  Next, this expert agreed with the prior opinion that airgun inoculation is a plausible route of hepatitis C transmission but found it most likely that the Veteran acquired hepatitis C from heroin use.  The VHA expert could not say with the certainty required (a 50 percent or greater probability) that airgun inoculation is how the Veteran acquired hepatitis C given his history of drug use, in other words.

Once again the Veteran denied ever using heroin in a February 2012 statement.

Based on the above, the Board finds that entitlement to service connection for hepatitis C is not warranted.  All of the requirements for this benefit, whether presumptive or direct, have not been met.

With respect to presumptive service connection, the chronic disease of cirrhosis of the liver was found in 2006 as well as diagnosed in 2009.  Yet there is no indication that it was present to a compensable degree within one year from the date of the Veteran's separation from service in November 1974.  Indeed, the record is devoid of any evidence dated during or even referencing the November 1974 to November 1975 time period.  

With respect to direct service connection, it is undisputed that the Veteran currently has hepatitis C.  Private treatment records contain a diagnosis of hepatitis C.  Hepatitis C also was diagnosed at the VA medical examination.  

The evidence concerning in-service hepatitis C risk factors, in contrast to that concerning a current diagnosis, is mixed.  The Veteran is competent to state that he transported Vietnam Veterans, shared drinks, had his ear pierced, shared razors, and received airgun injections during service because these occurrences are within his personal experience.  Layno v. Brown, 6. Vet. App. 465 (1994) (concluding that lay witnesses are competent to provide testimony or statements relating to facts of events that the lay witness observed or that is within the realm of his/her personal knowledge).  

Once evidence is determined to be competent, a determination on whether it also is credible must be made.  Id. (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")).  In weighing credibility, VA may consider factors such as a showing of interest, self-interest, bias, inconsistent statements, inconsistency with other evidence of record, facial implausibility, bad character, malingering, desire for monetary gain, and witness demeanor.  See Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991).  "[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence."  Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006).

Regarding transportation of Vietnam Veterans and sharing drinks, the Veteran is credible.  There appears to be no significant reason to doubt him.  He is interested in this matter because, depending on the outcome, he may gain financially.  However, it is facially plausible that he transported Vietnam Veterans and shared drinks during service.  No contradictory evidence exists.  

Yet the Veteran did not state that he was accidentally exposed to blood products by percutaneous or mucous membrane exposure as a result of transporting Vietnam Veterans.  No evidence of such an exposure is of record.  The Veteran indeed was a grenadier/infantryman rather than a health care worker, combat medic, or corpsman where accidental exposure to blood products is most likely.  Transportation of Vietnam Veterans therefore has not been established as a recognized in-service risk factor.  Further, sharing drinks, and thus saliva, additionally is not recognized as a risk factor for hepatitis C.  It is reiterated in this regard that hepatitis C is spread primarily by contact with blood and blood products.  VA Fast Letter 04-13 (June 29, 2004).

Regarding in-service ear piercing, the Veteran is not credible.  His contention concerning such piercing is inconsistent with another statement denying ever having any piercings, including during service.  Ear piercing accordingly has not been established as an in-service hepatitis C risk factor in this case.

Turning to the sharing of razors and receipt of airgun injections, the Veteran's credibility is unclear.  He indicated only that there was a great possibility that he had shared razors but did not remember if he actually did.  No evidence confirming joint use of a razor exists.  The Veteran indicated with certainty that he received airgun injections.  That he received several inoculations during service is undisputed.  Yet the manner in which they were given is not reflected.  In light of the approximate balance/relative equipoise of what little evidence is available for both of the aforementioned risk factors, the benefit of the doubt shall be afforded to the Veteran.  Sharing razors and receiving airgun injections thus have been established as in-service risk factors.

Two additional risk factors are notable in this case.  The Veteran's report that no risk factors other than those aforementioned applied to him is competent for the same reason as above.  His denials of using intravenous drugs and ever taking cocaine intranasally or heroin additionally are competent for this reason.  However, this is inconsistent with the mention of "drug abuse, heroin" during his service separation examination and his admitting to having a history of intravenous drug use in July 2006.  The Veteran is not credible given this inconsistency and the showing of interest in securing VA benefits it reveals.  It indeed has not gone unnoticed that he confessed to drug involvement immediately prior to filing his August 2006 claim but thereafter denied such involvement.  

As such, the Veteran is found to have the risk factor for hepatitis C of drug use.  His in-service drug use constitutes willful misconduct.  See 38 C.F.R. § 3.1(n) ("willful misconduct means an act involving conscious wrongdoing or known prohibited action...it involves deliberate or intentional wrongdoing with knowledge of or wanton and reckless disregard of its probable consequences"); 38 C.F.R. § 3.301(c)(2) ("the deliberate drinking of a known poisonous substance or under conditions which would raise a presumption to that effect will be considered willful misconduct").  Direct service connection can be granted only when a disability was incurred or aggravated in the line of duty not as a result of the Veteran's own willful misconduct or, for claims filed after October 31, 1990, the result of his abuse of alcohol or drugs.  38 C.F.R. § 3.301(c)(2).

Finally, the Veteran competently has reported having had five to six sexual partners in his lifetime.  He is credible in this regard because no significant reason is found to doubt him.  The evidence of record shows that at least some of his sexual activity with these partners was high-risk.  Specifically, the Veteran was treated for gonorrhea which was not recurrent during service.  High-risk sexual activity thus is established as an in-service risk factor.

Whether the Veteran's current hepatitis C is related to one of his established in-service risk factors which does not constitute willful misconduct (sharing razors, airgun inoculations, and high-risk sexual activity) is the remaining question.  No positive medical opinions exist in this regard.  Both the VA examiner and the VHA expert rendered negative opinions.  As pointed out by the Veteran's representative in a June 2009 statement and recognized by the Board in its November 2011 VHA expert opinion request, the rationale for the VA examiner's negative opinion is flawed.  That only a short period of the Veteran's adult life was spent in-service indeed is of no consequence since his exposure to hepatitis C could have been then.  No flaw is found with respect to the rationale provided by the VHA expert.

This expert agreed with the VA examiner that the in-service risk factor of airgun inoculations is a plausible cause of the Veteran's hepatitis C.  Yet, as noted in the opinion, this does not arise to the level of certainty required to establish proximal cause or aggravation.  See McLendon v. Nicholson, 20 Vet. App. 79 (2006); Bostain v. West, 11 Vet. App. 124 (1998); Goss v. Brown, 9 Vet. App. 109 (1996); Warren v. Brown, 6 Vet. App. 4 (1993); Beausoleil v. Brown, 8 Vet. App. 459 (1996); Obert v. Brown, 5 Vet. App. 30 (1993); Tirpak v. Derwinski, 2 Vet. App. 609 (1992) (collectively holding that language such as "it is possible," "it is within the realm of medical possibility," "could not rule out," "could have been," "may or may not," "may have," and similar generic statements insufficient).  No specific opinion was made with respect to sharing razors and high-risk sexual activity.  However, implicit in the VHA expert's opinion that the Veteran most likely acquired hepatitis C from heroin use is a rejection that the required level of certainty for either of these two in-service risk factors.

Acknowledgement is given to the Veteran's belief that his hepatitis C is related to one or more of his in-service risk factors which does not constitute willful misconduct.  Such a belief sometimes suffices to establish a causal relationship.  See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).  Yet this is not the case here.  The question of whether there is a service etiology in this case is medical and complex in nature, especially in light of the multiple risk factors/possible etiologies of varying strength.  Only those with specialized medical knowledge, training, and/or experience therefore are competent to answer this question.  See Jones v. West, 12 Vet. App. 460 (1999).  There is no indication that the Veteran possesses such knowledge, training, and/or experience.  Accordingly, he is a layperson and is not competent to render an etiology opinion regarding his hepatitis C.  See Cromley v. Brown, 7 Vet. App. 376 (1995); Espiritu v. Derwinski, 2 Vet. App. 492 (1992).  The only competent etiology opinions of record are not favorable, as discussed above.  

Of further note is that the Veteran's belief that his current hepatitis C is related to his service amounts to a conclusory declaration.  In a single judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation."  Richardson v. Shinseki, No. 08-0357, slip. op. at 4 (Vet. App. May 10, 2010).  While the Board recognizes that such single judge decisions carry no precedential weight, they may be relied upon for any persuasiveness or reasoning they contain.  See Bethea v. Derwinski, 2 Vet. App. 252 (1992).  

With respect to chronicity and continuity of symptomatology, it is notable that the Veteran does not contend he had hepatitis C or symptoms thereof during service as well as thereafter.  He instead reported being diagnosed approximately 30 years after service.  The evidence indeed reveals no complaints of, treatment for, or diagnosis regarding hepatitis C or its symptoms were recorded during service.  Hepatitis C additionally is not noted until over 31 years after the Veteran's separation from service.  A prolonged period without medical complaint or treatment can be considered as evidence against a claim.  See Maxson v. West, 12 Vet. App. 453 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000).  

It is well-recognized by the medical community that the incubation period for hepatitis C infection following exposure ranges from two to 26 weeks but onset of infection may be unrecognized for years because symptoms are not severe enough to require medical attention.  VA Training Letter 98-110; VA Training Letter 98-35 (April 8, 1998).  However, this does not negate the fact that neither chronicity nor continuity of symptomatology has been shown.  The incubation period and amount of time that can elapse between onset of infection and diagnosis indeed rather was taken into account above.  This information indeed was considered by the VHA expert given that it essentially was set forth in the request for a VHA expert opinion.

38 C.F.R. § 3.303(d) likewise is not of assistance to the Veteran.  His hepatitis C was diagnosed post-service.  However, all of the evidence does not establish that it was incurred during service through an in-service risk factor not due to willful misconduct.  It is reiterated that although the Veteran believes there is such a service nexus, a competent medical professional has opined otherwise.

In sum, the preponderance of the evidence is against awarding the Veteran service connection for hepatitis C under all pertinent theories of entitlement.  The doctrine of reasonable doubt thus is not applicable as it pertains to the overall outcome of the claim, which is denied.


ORDER

Service connection for hepatitis C is denied.



____________________________________________
JONATHAN B. KRAMER
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs