Patient-to-Patient Transmission of Hepatitis C Virus during Colonoscopy, 1997

To those interested in the possibility of transmission of viruses during colonoscopy procedures this 1997 New England Journal of Medicine article will be of interest. Also of interest is the ability to trace back to the infected Hep. C to the the original source described here.

The New England Journal of Medicine
http://content.nejm.org/cgi/content/full/337/4/237
Original Article
Brief Report

Volume 337:237-240 July 24, 1997 Number 4


Patient-to-Patient Transmission of Hepatitis C Virus during Colonoscopy
Jean-Pierre Bronowicki, M.D., Véronique Venard, Pharm.D., Christine Botté, M.D., Nathalie Monhoven, Ph.D., Isabelle Gastin, M.D., Laurence Choné, M.D., Hervé Hudziak, M.D., Bertrand Rhin, M.D., Christophe Delanoë, M.D., Alain LeFaou, M.D., Marc-André Bigard, M.D., and Pierre Gaucher, M.D.

Invasive diagnostic or therapeutic procedures may be a route for the transmission of the hepatitis C virus (HCV).1,2,3,4,5 In a study of patients in a gastrointestinal-disease unit, endoscopic biopsies were found to be an independent risk factor for HCV infection.6 We report the transmission of HCV during colonoscopy from a person known to have HCV infection to two other patients. The patient-to-patient transmission was ascertained by sequencing the nucleotides in the various HCV isolates.

Case Report

A 55-year-old man (Patient 1) and his 54-year-old wife (Patient 2) were referred in October 1995. In June 1995, both had had hepatitis-like illnesses, with nausea, abdominal pain, and conjunctival icterus. They had elevated serum alanine aminotransferase levels and tested positive for HCV antibodies by third-generation assays (Ortho Diagnostic Systems, Roissy en France, France, and Pasteur Diagnostique, Marnes-la-Coquette, France). Both had been regular blood donors for 20 years; they had had normal liver-enzyme levels and negative HCV serologic tests at the time of their most recent blood donations, in January 1995. They had not had blood transfusions, and there was no evidence of intravenous drug use. However, both patients had family histories of colon cancer, and both had undergone colonoscopy on March 16, 1995. Their serum alanine aminotransferase levels one week earlier were normal. Neither patient had previously undergone endoscopy in the same unit.

Liver biopsies were performed in both patients in November 1995, and the histologic activity was measured by the Knodell score.7 The biopsies revealed chronic hepatitis, minimal in Patient 2 and moderate in Patient 1 (Knodell scores, 3 and 9, respectively). No fibrosis was found in either biopsy specimen. The results of serologic tests for HCV were confirmed by third-generation enzyme immunoassays (Ortho Diagnostic Systems and Abbott Diagnostic Division, Rungis, France). Both patients tested negative for hepatitis B virus (HBV) and human immunodeficiency virus (HIV) types 1 and 2.

Methods

The temporal relation between HCV positivity and colonoscopy in the two patients led us to suspect a nosocomial infection (Figure 1). We investigated whether any HCV-positive patients had undergone colonoscopy in the clinic on the same day as our patients and whether any staff member performing endoscopy was HCV-positive. By genotyping and nucleotide sequencing of the HCV genome, we compared the virus isolated from our patients with that isolated from a patient known to be HCV-positive. We studied the procedures used for anesthesia and colonoscopy, in particular the techniques used in cleaning and disinfecting the endoscopes, to try to determine a possible route of infection.


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Figure 1. Clinical, Biochemical, Serologic, and Molecular Profiles of Patients 1 and 2.

In these patients, who acquired HCV infection after undergoing colonoscopy, HCV antibodies were detected by third-generation tests and HCV RNA was detected in serum by reverse-transcription PCR, as described in the Methods section. Alanine aminotransferase values are shown on a logarithmic scale, and the horizontal lines indicate the upper limit of the normal range. NT denotes not tested.


All the staff members involved in performing endoscopy (one gastroenterologist, one anesthetist, one nurse, and one nurse's aide) tested negative for HCV serology by third-generation assays. Only three colonoscopies were performed on March 16, 1995. The first involved a 42-year-old woman (Patient 3) with a history of polypectomy. She was known to have been HCV-positive for one year, but she had not been treated because she had chronic depression. In November 1995, her serum alanine aminotransferase level was 43 IU per liter (normal level, <40). Serologic tests were positive for HCV and negative for HBV and HIV.

Detection and Titration of HCV RNA

Serum samples from Patients 1 and 2 collected in January 1995 at the time of blood donation and frozen at -80°C and serum samples obtained from Patients 1, 2, and 3 in October and November 1995 were tested for HCV RNA by a reverse-transcription polymerase chain reaction (PCR) with primers from the highly conserved 5' noncoding region of the HCV genome (Table 1). Briefly, RNA was extracted from 100 µl of serum with use of the method described by Chomczynski and Sacchi.9 RNA samples were heated for 10 minutes at 70°C and then incubated for 60 minutes at 37°C in a reaction mixture containing reverse-transcription buffer, 10 mM dithiothreitol, 1 mM of each deoxynucleotide triphosphate, 10 U of RNAsin (Life Technologies, Cergy Pontoise, France), 200 U of reverse transcriptase of Moloney murine leukemia virus (Life Technologies), and 0.4 mM outer antisense primer. The samples were then heated to 100°C for 10 minutes. Distilled water, extraction buffer, and HCV-negative serum samples were used as negative controls. Serum positive for HCV RNA served as a positive control. The complementary DNA (cDNA) was amplified by a nested PCR.10 The first PCR was performed in a 50-µl reaction mixture containing Taq polymerase buffer, 1 mM of each deoxynucleotide triphosphate, 1.5 mM magnesium chloride, 1 mM of each outer primer, 1 U of Taq polymerase (Life Technologies), and 5 µl of cDNA. There were 35 PCR cycles consisting of denaturation at 95°C for one minute, annealing at 55°C for one minute, and extension at 72°C for one minute.

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Table 1. Nucleotide Sequences and Positions of HCV Primers.


The second PCR reaction was performed as described above for 25 cycles, with 5 µl of the first PCR product and the inner primers. The PCR products were subjected to electrophoresis in 2 percent agarose gels, stained with ethidium bromide, and visualized under ultraviolet light. The expected size of the amplification product was 190 bp.

HCV RNA was measured in serum by a branched-chain DNA assay (Quantiplex bDNA 2.00, Chiron Diagnostics Europe, Cergy Pontoise, France) in accordance with the instructions of the manufacturer.

HCV Genotyping and Nucleotide Sequencing

HCV genotyping was performed by a line-probe assay according to the instructions of the manufacturer (Innogenetics, Antwerp, Belgium). This assay is based on variations in the 5' untranslated regions of the various HCV genotypes. In the line-probe assay, type-specific probes are tagged with poly(T) tails by terminal deoxynucleotidyl transferase and attached to nitrocellulose membranes. Amplified products labeled with biotin are hybridized in reverse to the probes on the nitrocellulose strip. The biotin group is incorporated by using a 5'-biotinylated primer during the amplification. The labeled product obtained from the 5' untranslated region hybridizes with the probe that has a perfect match of sequences. After hybridization, streptavidin labeled with alkaline phosphatase is added and bound to any biotinylated hybrid formed. This technique allows the six major types of HCV and their most common subtypes to be detected.

To study the HCV sequences in the three patients, we performed a nested reverse-transcription PCR in nonstructural region 3 (NS3) with the patients' serum samples (using the primers described in Table 1). The NS3 region probably codes for a protease and helicase. Serum positive for HCV genotype 1b was used as a positive control, and serum negative for HCV RNA was used as a negative control. The NS3 region was chosen for the analysis of sequencing because the 5' noncoding and core regions appear to be quite conserved among the various types of HCV, whereas the putative envelope regions are highly variable even among examples of the same HCV subtype.11

To check the size of the amplification products, the PCR products were subjected to electrophoresis in 2 percent agarose gels and visualized with ethidium bromide staining (expected size, 186 bp). Each sample was tested in triplicate. The PCR products were gently separated from the agarose gel, purified by separation with a minicolumn (Wizard A7170, Promega, Madison, Wis.), and eluted in 50 µl of distilled water. The total yield of DNA was determined by spectrophotometry; 100 ng of purified DNA product was used in the cycle-sequencing reactions (Prism 401388, Applied Biosystems, Foster City, Calif.), which were performed according to the instructions of the manufacturer. The sequencing products were analyzed with a DNA-sequencing system (Model 373 A, Applied Biosystems). At least two sequencing reactions were performed with each sample, with the appropriate sense and antisense primers (Table 1). The sequences were aligned with use of the Clustal V program, which is widely employed to study the alignment of multiple sequences.12 This software is marketed under various names by various manufacturers. We used Assemblylign (Kodak International Biotechnologies, New Haven, Conn.). The nucleotide alignments were compared among the three patients, the control serum positive for HCV genotype 1b, and the published sequence of HCV genotype 1b.8,13

Results

Detection and Quantitation of HCV RNA

The serum samples collected from Patients 1 and 2 in January 1995 tested negative for HCV RNA, whereas those obtained in October and November 1995 tested positive. The level of viremia of Patient 3 in November 1995 was 3.5 million genome equivalents per milliliter.

Genotyping and Sequencing of HCV

All three patients were infected with HCV genotype 1b. Nucleotide sequencing of the NS3 region showed that the three patients were all infected with the same isolate, because there was 100 percent nucleotide homology among the three clones. The degree of homology between the nucleotides in the NS3 region, the control serum positive for HCV genotype 1b, and the published sequences of HCV-BK8 and HCV-J13 genotype 1b isolates ranged from 86.9 percent to 89 percent. The degree of homology in the amino acid sequences deduced from the nucleotide sequences ranged from 89.6 to 96 percent (Figure 2).


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Figure 2. Nucleotide Sequence of the HCV NS3 Gene Region in the Three Patients Who Underwent Colonoscopy on March 16, 1995, as Compared with the Sequence in Control Serum Positive for HCV Genotype 1b and Two Published Sequences of That Genotype.

There was 100 percent homology among the three patients with respect to the nucleotides sequenced. The dashes in the control and published sequences denote nucleotides identical to those sequenced in the patients; only divergent nucleotides are shown. Underscoring denotes a change in the amino acid sequence expected on the basis of the coding information. Amino acid sequences were not determined. Shading has been added to facilitate the comparison of the sequences.


Procedures Used for Colonoscopy, Disinfection, and Anesthesia

Patient 3 underwent colonoscopy from 10:10 to 10:30 a.m., and Patient 2 underwent the procedure from 11:00 to 11:30 a.m. Multiple biopsy specimens were obtained from both patients, because micropolyps were found. Patient 1 had a polypectomy between noon and 12:30 p.m. in which a diathermic loop was used. The same colonoscope (Olympus, Tokyo, Japan) was used throughout all three procedures. The biopsy specimens from Patients 2 and 3 were obtained with the same forceps.

After each procedure, the colonoscope was immediately immersed for 10 minutes in water containing detergent and washed on the outside with disposable swabs. The air, water, and biopsy-suction channels were washed with the same detergent as the colonoscope, with an all-channel irrigator (Olympus). After being rinsed with water, the endoscope and all the internal channels were soaked for five minutes in 2 percent glutaraldehyde. Rinsing in water and drying with compressed air followed.

During the procedures, the biopsy-suction channel was never thoroughly cleaned with an appropriate brush. A consensus report on endoscope disinfection14 has emphasized that the brush used in cleaning should be appropriate for the instrument and channel size. This mechanical cleaning is used to remove residual tissue, the presence of which may contribute to the failure of the cleaning and disinfection procedures. In interviews, nurses stated that this cleaning step was never performed in the clinic. After each procedure, the biopsy forceps and the diathermic loop were cleaned mechanically in detergent and in glutaraldehyde, but they were not autoclaved.

The same procedure for anesthesia was used in each patient. An intravenous line was inserted, and anesthesia was induced by injecting fentanyl and midazolam directly into the line. Anesthesia was maintained by injecting propofol continuously into the intravenous line with an electric syringe. The intravenous tubing was changed after each patient's procedure. Because Patient 3 was known to be HCV-positive, the intravenous line and the syringes used to inject the fentanyl, midazolam, and propofol were thrown away after that patient's procedure, which was the first of the three. During the interval between the procedures in Patient 2 and Patient 1, the intravenous lines and the needles were changed, but the same syringes of fentanyl, midazolam, and propofol were used.

Discussion

The timing of the events and the molecular characterization of the various HCV isolates provide evidence that HCV was transmitted during colonoscopy. There are few documented cases of viral transmission during endoscopy.15 One case of transmission of HBV in this manner has been reported.16 Acute hepatitis C was reported in a patient 10 weeks after the patient underwent retrograde cholangiography with sphincterotomy; no genotyping or nucleotide sequencing was performed, and HCV could not be proved to have been transmitted during the endoscopy.17 In both these cases, the disinfection procedure used was considered inadequate.

We suggest that during the disinfection of the colonoscope after the procedures in the patients we describe, two recommendations on endoscopic disinfection made by the American Society for Gastrointestinal Endoscopy14 and the British Society of Gastroenterology18 and the working party of the World Congresses of Gastroenterology19 were not followed. From our investigation it appeared that the biopsy-suction channel was never cleaned with a brush and that the accessories that breach the mucosa, such as the biopsy forceps and the diathermic loop, were not autoclaved after each use. Recently, the effectiveness of manual cleaning and disinfection in preventing the transmission of HCV was assessed by testing the effluent from the endoscope biopsy channel by reverse-transcription PCR for the presence of HCV RNA.20 That study involved 39 patients with chronic hepatitis C who underwent gastroscopy with biopsy. Sterile water was flushed through the biopsy channel immediately after the removal of the endoscope, after cleaning with a detergent solution, and after a final disinfection with glutaraldehyde. HCV RNA was found in two cases before the cleaning with a detergent, but in every case the water flushed through the biopsy channel after the cleaning step and after the disinfection with glutaraldehyde was negative for HCV RNA.20 These findings confirm that the disinfection procedure is effective when all the recommendations are followed.

Other studies assessing the degree of adherence to guidelines for the cleaning and disinfection of gastrointestinal endoscopes have pointed out the high rate of inadequate disinfection procedures (30 to 100 percent).14 Failure to follow the recommended procedures can have an important role in the endoscopic transmission of microorganisms.

The possibility that HCV was transmitted because of inadequate procedures in the use of anesthesia should also be considered. We believe this route of transmission is less likely, because the intravenous tubing and all the syringes containing the anesthetic drugs were changed after the first colonoscopy, in which the patient evaluated was known to be HCV-positive. However, inadequate procedures were followed during the other two procedures. Only the intravenous tubing and the needles were changed between the endoscopies of Patients 2 and 1. The anesthetist stated that he discarded syringes only after they were used in a patient known to be infected. To justify this approach, he said that he systematically used a check valve to avoid the backflow of blood into the syringe. However, other studies have shown that the rate at which blood contaminates the intravenous tubing used for anesthesia is substantial (0.3 to 3.3 percent of cases).21,22,23 The presence of a check valve and the changing of the needle do not affect the rate at which intravenous lines and syringes become contaminated — a point that should be emphasized, because multidose vials are very commonly used in anesthesia.21,22,23 Moreover, because the assessment of risk factors is not a reliable predictor of which patients have chronic viral infection, the practice of following strict procedures for anesthesia only in patients with known infections has little rationale and should be abandoned. The standard of care should be to use equipment and ampules only once.

We are indebted to Dr. M.P. Mahoney for his help in preparing this article.


Source Information

From the Service d'Hépato-Gastroentérologie (J.-P.B., L.C., H.H., C.D., M.-A.B., P.G.), the Laboratoire de Microbiologie (V.V., B.R., A.L.), the Etablissement de Transfusion Sanguine (C.B.), the Laboratoire Commun de Biologie Moléculaire (N.M.), and the Laboratoire de Pathologie Cellulaire et Moléculaire en Nutrition (J.-P.B., I.G., M.-A.B., P.G.), Faculté de Médecine et Centre Hospitalier Universitaire de Nancy, Vandoeuvre, France.

Address reprint requests to Dr. Bronowicki at the Service d'Hépato-Gastroentérologie, CHU de Nancy, 54500 Vandoeuvre, France.

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Veterans Court comments on "sympathetically read", Ingram v. Nicholson, No. 03-2196

In addition to "sympathetically read",:

alleging injury under 38 U.S.C.[] 1151:

"Specifically, there was no allegation of negligence or lack of proper skill, nor did the veteran make some other allegation of the surgery having been done improperly, as to the pneumonectomy that was done at that time."

=========================================
Pending Claims:

"we conclude that the Federal Circuit has neither overruled the pending claim doctrine articulated in Norris nor created a general doctrine of sub silentio denials that supplants the pending claim doctrine. We conclude Deshotel and Andrews stand for the proposition that, where an RO decision discusses a claim in terms sufficient to put the claimant on notice that it was being considered and rejected, then it constitutes a denial of that claim even if the formal adjudicative language does not "specifically" deny that claim. Because we find no such denial in this case, the appellant is correct that we have jurisdiction over his appeal because it is not a collateral attack on the final 1986 RO decision.

Treating the Secretary's failure to sympathetically read and adjudicate a reasonably raised claim as a pending claim benefits veterans because it protects their appellate rights and works no hardship on the Secretary in that it requires only that each claim be specifically addressed.

the Federal Circuit's holding in Andrews has on this case. Specifically, the Court referred to Andrews' conclusion that "when VA violates Roberson[ v. Principi, 251 F.3d 1378 (Fed. Cir. 2001),] by failing to construe the veteran's pleadings to raise a claim, such claim is not considered unadjudicated but the error is instead properly corrected through a [clear and unmistakable error (CUE)] motion." 421 F.3d at 1284.

===============================================
Pending claim for a benefit has not received an initial decision:

"Under Myers, the appellant can argue that an earlier claim for the
benefits should be considered part of the same claim stream that eventually resulted in the award of benefits for the purpose of establishing the effective date. If a veteran believes that he has a pending claim for a benefit that has not received an initial decision, the veteran can unambiguously inform the Secretary that a particular benefit is being sought. The Secretary must then decide entitlement to the benefit and-if relevant-address the issue of when the claim was first raised. See DiCarlo, 19 Vet.App. at __, slip op. at 7 (holding that the finality of a specific claim is an issue that can be raised when relevant, but is not a procedure or claim in and of itself)."

===============================================
Piecemeal Nature of Veterans Claims:

Veterans benefits litigation is frequently piecemeal. Claims made in a single document may be decided by separate rating decisions if some need development while others do not. See VA Adjudication Procedure Manual (M21-1) Part III para. 2.01(h)(1)(b) ("Identifying Partial Grants"); see also Amicus PVA Br., Exhibit C (VA Adjudication Procedure Manual Rewrite, Part III, Subpart IV, Chapter 6, Section A ("Partial and deferred Rating Decisions")). Furthermore, quite often a veteran will not submit a single document. Instead, he will submit a continuous stream of evidence and correspondence. Rather than holding all the claims until every one is ready to be decided, the Secretary develops and decides multiple claims separately-often over a period of years. A veteran could easily submit what he believes to be a claim and receive from the Secretary an adjudication of a previously raised claim for the same disability. The veteran could then submit more correspondence on the claim he was trying to raise and receive a request from the Secretary for evidence or to report for an examination. There could be years of intervening appeals, remands, and revised decisions before the claim is actually granted and the assignment of the effective date reveals that the Secretary did not recognize the initial submission as a claim for the benefit. In the meantime, the decision that sub silentio denied the claim that the appellant alleges was reasonably raised has become final and can only be challenged for CUE. Once again, the veteran would have been denied direct review of the sub silentio denial because he had no reason to know that was an issue at the time he could have appealed that decision.

===============================================
sub silentio:

"Moreover, even a savvy veteran may not be aware that there is a
disagreement as to which document raised a claim until after an effective date is assigned. Veterans benefits litigation is frequently piecemeal.
A veteran will submit a continuous stream of evidence and correspondence.
Rather than holding all the claims until every one is ready to be decided, the Secretary will develop and decide multiple claims separately-often over a period of years. A savvy veteran could easily submit what he believes to be a claim and receive from the Secretary an adjudication of a previously raised claim for the same disability. The veteran could then submit more correspondence on the claim he was trying to raise and receive a request from the Secretary for evidence or to report for an examination.
There could be years of intervening appeals, remands, and revised
decisions before the claim is actually granted and the assignment of the effective date reveals that the Secretary did not recognize the initial submission as a claim for the benefit. In the meantime, the decision that sub silentio denied the claim that the appellant alleges was reasonably raised has become final and can only be challenged for CUE.
Once again, the veteran would have been denied direct review of the sub silentio denial because he had no reason to know that was an issue at the time he could have appealed that decision. Accordingly, accepting a doctrine of sub silentio denials has grave implications for due process and protecting the appellate rights of veterans."

===============================================
When a claim raised and version or versions of the law are relevant:

"This is not to say that the question of when a claim was raised will never be relevant before an effective date is assigned. It may be relevant, for example, to determining which version or versions of the law are relevant to the substantive question of entitlement. See Rodriguez v. Nicholson, 19 Vet.App. 275, 288-89 (2005) (discussing considerations relevant to determining which version of a statute or regulation should apply when there is a change during the pendency of a case)."
===============================================

"The question presented to the Court is not whether the Secretary has a duty to sympathetically read a pro se veteran's filings to determine whether a claim has been raised. It is beyond question that the Secretary has such a duty and that it applies not just to total disability based on individual unemployability (TDIU) ratings, but also to any claim for benefits. See Szemraj v. Principi, 357 F.3d 1370 (Fed. Cir. 2004)."

"The question presented to this Court is the proper procedural time and mechanism to assert an alleged failure of the Secretary to perform this duty."

"Beverly v. Nicholson, 19 Vet.App. 394, 405 (2005) (whether a sympathetic reading of filings raises a claim is a question of fact)."

"There is no suggestion in Roberson that a decision on a wholly different claim could be regarded as a final decision on a claim not mentioned in that decision."

"the Federal Circuit went on to clarify:
[A]part from the requirement that a pro se veteran's pleadings be read sympathetically, our decision in Roberson did not change the well-established legal standard for determining the existence of CUE in RO and BVA decisions. See Cook, 318 F.3d at 1344. . . . In Cook we held en banc that in order to constitute CUE, the alleged error must be both "outcome determinative" and "based upon the evidence of record at the time of the original decision. 318 F.3d at 1344. . . ."

"Contrary to the appellant's argument, Roberson does not require VA to reconcile the conflicting evidence before adjudication, nor does it require the agency to develop evidence on the veteran's theory. To construe Roberson as requiring factual development as a matter of course would be to effectively overrule our decision in Cook that the failure to assist in developing the evidentiary record cannot constitute CUE. See id. Szemraj, 357 F.3d at 1375-76 (emphasis added)."

"Reading Andrews as broadly as the Secretary suggests would run afoul of the due process concerns voiced by the en banc Federal Circuit in Cook and by this Court in Thurber v. Brown, 5 Vet.App. 119, 123 (1993), where we noted that "VA's nonadversarial claims system is predicated upon a structure which provides for notice and an opportunity to be heard at virtually every step in the process." See 38 U.S.C. 5104(a) (requiring the Secretary, when making a decision affecting the provision of benefits to a claimant, to "provide to the claimant . . . notice of such decision"), 5104(b) (requiring the Secretary, when denying a benefit sought, to provide a statement of the reasons for the decision and a summary of the evidence considered); 38 C.F.R. 3.103(b) (2005) ("Claimants and their representatives are entitled to notice of any decision made by VA affecting the payment of benefits or the granting of relief.")."

===============================================
Duty to sympathetically read and adjudicate:

"That duty [to sympathetically read and adjudicate] primarily helps those veterans who have not clearly articulated that they are seeking a particular benefit. It is illogical to expect such veterans to immediately recognize when the Secretary has failed to adjudicate a reasonably raised claim because it is ignorance of the intricacies of potential claims that makes the duty necessary. "

"In this case, it is premature for us to determine whether the Board's finding was clearly erroneous because its denial was based on the application of overly strict requirements that were inconsistent with the Secretary's duty to sympathetically read pro se pleadings. Although we need not formulate a specific standard at this time, we note that the duty to sympathetically read must be based on reasonable expectations of a pro se claimant and the Secretary. It is the pro se claimant who knows what symptoms he is experiencing that are causing him disability, see Cintron v. West, 13 Vet.App. 251, 259 (1999) ("[c]ertainly, the RO had no obligation to read the mind[] of the veteran"), and may assert potential causes of the disability even if he is not competent to make a medical diagnosis, see Espiritu v. Derwinski, 2 Vet.App. 492, 494 (1992) (holding that lay person is not competent to offer evidence that requires medical knowledge)."

"The Board's suggestion that the appellant was required to articulate a specific intent to "claim . . . compensation benefits under the provisions of 38 U.S.C.A. 1151" is similarly flawed. R. at 8, 9. The duty to sympathetically read exists because a pro se claimant is not presumed to know the contents of title 38 or to be able to identify the specific legal provisions that would entitle him to compensation. Again, there would be no need for the duty to sympathetically read pleadings if pro se claimants had encyclopedic knowledge of veterans law."

"Finally, we hold that it was also error for the Board to suggest that it was limiting the material being reviewed to the "four corners" of the application and the statement in support of the claim. Cf. EF v. Derwinski, 1 Vet.App. 324, 326 (1991) (holding that VA's duty to give a liberal reading to an appeal of an RO decision applies to "all documents or oral testimony submitted prior to the B[oard] decision")."

"the Board's articulation of a "four corners" standard for reviewing the appellant's pleadings is overly formal in a system where the Secretary must take a sympathetic view of an appellant's pleadings to determine whether a claim has been made."

"In summary, a sympathetic reading of the appellant's pleadings cannot be based on a standard that requires legal sophistication beyond that which can be expected of a lay claimant and must consider whether the appellant's submissions, considered in toto, have articulated a claim."

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Robert J. Ingram v. Nicholson, No. 03-2196 (Argued February 22, 2006, Decided July 12, 2006 )

"In summary, a sympathetic reading of the appellant's pleadings cannot be based on a standard that requires legal sophistication beyond that which can be expected of a lay claimant and must consider whether the appellant's submissions, considered in toto, have articulated a claim."
==============================================

"The duty to sympathetically read exists because a pro se claimant is not presumed to know the contents of title 38
or to be able to identify the specific legal provisions that would entitle him to compensation."
===============================================

"The Board focused on whether the appellant had alleged negligence or a lack of proper skill on the part of the VA physicians and whether he had expressed an intent to apply for section 1151 benefits. R. at 8-9. Both of these forms of analysis were legally incorrect.

As the Federal Circuit explained in Hodge v. West, 155 F.3d 1356, 1362-63 (Fed. Cir. 1998), when it announced the sympathetic-reading requirement based on the legislative history of the Veterans' Judicial Review Act and Veterans' Benefits Improvement Act of 1988, Congress intended to preserve the nonadversarial nature of the VA system wherein the Secretary provides claimants with assistance in submitting and substantiating claims."
===============================================

"Although there is no statutory or regulatory definition of "sympathetic reading," it is clear from the purpose of the doctrine that it includes a duty to apply some level of expertise in reading documents to recognize the existence of possible claims that an unsophisticated pro se claimant would not be expected to be able to articulate clearly. Cf. Andrews, 421 F.3d at 1283 (holding that the duty to sympathetically read submissions does not apply to pleadings through counsel).
===============================================

"it is precisely because unsophisticated claimants cannot be presumed to know the law and plead claims based on legal elements that the Secretary must look at the conditions stated and the causes averred in a pro se pleading to determine whether they reasonably suggest the possibility of a claim for a benefit under title 38, regardless of whether the appellant demonstrates an understanding that such a benefit exists or of the technical elements of such a claim."
===============================================

"Finally, we hold that it was also error for the Board to suggest that it was limiting the material being reviewed to the "four corners" of the application and the statement in support of the claim. Cf. EF v. Derwinski, 1 Vet.App. 324, 326 (1991) (holding that VA's duty to give a liberal reading to an appeal of an RO decision applies to "all documents or oral testimony submitted prior to the B[oard] decision")."
===============================================

"Finally, we do not hold that the Secretary's failure to adjudicate a reasonably raised claim can never be the basis for a CUE motion. Rather it can be the basis of a CUE motion as to a final decision of the Secretary where the issue was relevant to a decision actually made. As discussed above, Moody is a good example. Because the effective-date decision in that case had become final, the appellant properly alleged CUE in the effective-date decision on the theory that it failed to correctly identify which document was the appellant's claim for purposes of assigning an effective date under section 5110. The appellant's theory in this case is no different from the theory of the appellant in Moody. The only difference is that, as a matter of procedure, the appellant here has directly appealed his effective-date decision rather than allowing it to become final. See Beverly, 19 Vet.App. at 406 ("It would be illogical and unfair to require the appellant to wait until the Board decision is final and then face the high burden of proving CUE when any other error can be addressed immediately and more favorably when raised in a timely manner.")"
===============================================

"As to the Board's suggestion that the appellant was required to
allege negligence or lack of skill, measuring the appellant's submissions against a strict pleading requirement is fundamentally inconsistent with the concept of a sympathetic reading and, therefore, constituted legal error by the Board. The application of such a pleading requirement violates the duty to sympathetically read submissions because it required the appellant to demonstrate a level of sophistication that would render moot the duty to sympathetically read his pleadings. In other words, it is precisely because unsophisticated claimants cannot be presumed to know the law and plead claims based on legal elements that the Secretary must look at the conditions stated and the causes averred in a pro se pleading to determine whether they reasonably suggest the possibility of a claim for a benefit under title 38, regardless of whether the appellant demonstrates an understanding that such a benefit exists or of the technical elements of such a claim. The Board's suggestion that the appellant was required to articulate a specific intent to "claim . . . compensation benefits under the provisions of 38 U.S.C.A. 1151" is similarly flawed. R. at 8, 9."
===============================================
===============================================

UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS

No. 03-2196

Robert J. Ingram, Appellant,
v.
R. James Nicholson,
Secretary of Veterans Affairs, Appellee.


On Appeal from the Board of Veterans' Appeals

(Argued February 22, 2006, Decided July 12, 2006 )

Arie M. Michelsohn, of Washington, D.C., with whom Mark R. Lippman of La Jolla, California was on the brief, for the appellant.

Jeffrey Schueller, with whom Tim S. McClain, General Counsel; R. Randall Campbell, Assistant General Counsel; Carolyn F. Washington, Deputy Assistant General Counsel; and Lavinia A. Derr were on the brief, all of Washington, D.C., for the appellee.

Before MOORMAN, LANCE, and SCHOELEN, Judges.

LANCE, Judge: The appellant, veteran Robert J. Ingram, appeals
through counsel a December 12, 2003, decision of the Board of Veterans' Appeals (Board) that denied entitlement to an effective date earlier than April 15, 1992, for the grant of compensation benefits under 38 U.S.C. 1151 for residuals of a pneumonectomy. Record (R.) at 1-10. The parties each filed briefs, and the appellant filed a reply brief. Subsequently, the Court sua sponte ordered the parties to file supplemental briefs addressing what impact, if any, the holding of the United States Court of Appeals for the Federal Circuit (Federal Circuit) in Andrews v. Nicholson, 421 F.3d 1278 (Fed. Cir. 2005), has on this case.
Thereafter, the Court heard oral arguments in the case. For the reasons that follow, the Court will vacate the Board decision and remand the matter for further proceedings.


I. FACTS
The appellant served on active duty in the U.S. Marine Corps from
September 1964 to September 1968. R. at 14. In April 1985, he underwent a right bronchoscopy and right pneumonectomy at a VA medical center in Salt Lake City, Utah. R. at 16-21. On May 8, 1986, the Los Angeles, California, VA regional office (RO) received the appellant's initial formal application for VA benefits. R. at 23-26. The appellant submitted his claim on VA Form 21-526, Veteran's Application for Compensation or Pension. R. at 23-26. Under the section entitled "Nature and History of
Disabilities" and in response to item 24, entitled "Nature of sickness, disease or injuries for which this claim is made and date each began," the appellant wrote: "Feb.-1985-Right lung was removed, Salt Lake City, Utah, VA Hospital." R. at 24. He also provided responses to items 29A through 32E, under the section entitled "if you claim to be totally disabled," as well as responses to items 33A through 33E, and items 34A through 39B,
which contained the instruction that these items should be completed only if the applicant is applying for "non-service-connected pension." R. at 25- 26.
On August 12, 1986, the RO received the appellant's statement in
support of claim wherein he stated:
The removal of a vital organ (right lung) has greatly decreased
my capacity for air-lung capacity-by fifty percent. Also[,] I am not
capable under this condition to continue my normal life style.

I attend[ed] four years of carpenter apprenticeship course at
Orange Coast College in Coast Mesa, CA, 1972-1975, to obtain a
skillful trade, but now under these adverse medical condition[s], I
am unable to continue in my skillful trade. R. at 34. On August 14, 1986, the RO denied a claim for non-service-connected pension benefits because he was not considered permanently unemployable. R. at 28. The appellant did not appeal that decision.
On April 15, 1992, the appellant filed a second VA Form 21-526,
Veteran's Application for Compensation or Pension. R. at 50-53. Under the section entitled "Nature of sickness, disease or injuries for which this claim is made and date each began," the appellant wrote: "Right Pneumonectomy 1985[;] Esophageal fistual 1986[;] Gastrostomy Tube 1986." R. at 51. In June 1992, the appellant submitted correspondence to the RO asserting, inter alia, that as a result of the 1985 surgery and VA's negligence, he developed an esophageal leak. R. at 57. In June 1995, the RO denied his claim for benefits under 38 U.S.C. 1151 for disability caused by VA treatment. R. at 352-56. However, on appeal in June 1999, the Board awarded compensation benefits under 38 U.S.C. 1151 for residuals of a pneumonectomy based on an additional disability resulting from treatment in a VA facility. R. at 427-37. On
January 20, 2000, the RO awarded a 60% disability rating, effective from October 7, 1996. R. at 456-59. The appellant filed a Notice of Disagreement (NOD) in May 2000, and the RO issued a Statement of the Case (SOC) in February 2002 assigning an earlier effective date of April 15, 1992. R. at 461, 470-77. The veteran perfected his appeal to the Board. R. at 479.
In the decision on appeal, the Board denied an effective date earlier
than April 15, 1992. R. at 1- 10. In denying the appellant's request for an earlier effective date, the Board determined, inter alia, that neither his May 1986 application for benefits nor his August 1986 statement in support of claim could have been construed as a claim for compensation benefits under 38 U.S.C. 1151, and therefore, an effective date back to 1986 was not warranted. R. at 8-9. In reaching this conclusion, the Board stated: "There is nothing in the four corners of [the May 1986 application] that showed an intent that the veteran was claiming compensation benefits under the provisions of 38 U.S.C.[] 1151.
Specifically, there was no allegation of negligence or lack of proper skill, nor did the veteran make some other allegation of the surgery having been done improperly, as to the pneumonectomy that was done at that time." R. at 8. The Board further concluded that there was nothing in the appellant's August 1986 assertion that the surgery had reduced his lung capacity by 50 % "when read alone or with the VA Form 21-526, [that] would indicate an intent to file a claim for compensation benefits under
the provisions of 38 U.S.C. 1151. Again, the veteran was not claiming that the surgery was done improperly or that VA had committed negligence or showed lack of proper skill in performing the pneumonectomy." R. at 9.
Based on this analysis, the Board concluded that the preponderance of the evidence was against finding that the veteran had filed a claim under section 1151 in 1986. R. at 9.


II. THE PARTIES' ARGUMENTS
On appeal, the appellant asserts that the Board erred in 2003 when it determined that his May 1986 and August 1986 filings did not constitute informal claims for compensation benefits under 38 U.S.C. 1151, which would have entitled him to the assignment of an earlier effective date.
Appellant's Brief (Br.) at 3-9; see Norris v. West, 12 Vet.App. 413 (1999) (holding that when an RO fails to adjudicate a reasonably raised claim it remains pending). In this regard, he maintains that VA had a duty to sympathetically read his pro se pleadings and determine all potential claims raised by the evidence, and therefore, the Board erred when it treated his 1986 application as one exclusively for pension benefits. Br. at 4-5. In response, the Secretary maintains that there was no indication in either filing that demonstrated an intent by the appellant that he was claiming benefits under 38 U.S.C. 1151. Secretary's Br. at 4-10.
On October 4, 2005, the Court sua sponte ordered the parties to file
supplemental briefs addressing what impact, if any, the Federal Circuit's holding in Andrews has on this case. Specifically, the Court referred to Andrews' conclusion that "when VA violates Roberson[ v. Principi, 251 F.3d 1378 (Fed. Cir. 2001),] by failing to construe the veteran's pleadings to raise a claim, such claim is not considered unadjudicated but the error is instead properly corrected through a [clear and unmistakable error (]CUE[)]
motion." 421 F.3d at 1284. Both parties submitted supplemental briefs
asserting that Andrews did not overrule the longstanding jurisprudence
regarding pending claims and the statutory and regulatory framework
underlying it. Both parties suggested that anything other than a narrow
reading of Andrews would be unworkable because if the failure to construe
a claim needs to be raised in the context of CUE, then under the facts of
this case, the Court would have to find a finally adjudicated section 1151
claim in 1986-which is not shown in the record on appeal. Without any RO
decision, there is no indication of the evidence of record concerning the
claim, applicable law and regulation governing the claim, or any analysis
applying the facts to the legal criteria-all inherent to any CUE challenge
. CUE necessarily requires a previous determination that is final and
binding. The Secretary's supplemental brief also points out that the
Federal Circuit's own interpretation of Andrews suggests a narrow reading
because in Bingham v. Nicholson, 421 F.3d 1346, 1349 (Fed. Cir. 2005),
the panel stated: "[A]s we recently held in Andrews, the VA's failure
to consider all aspects of a claim does not render its decision non-final
but instead 'is properly challenged through a CUE motion.'" (Emphasis
added.)
At oral argument, the appellant maintained his prior position.
However, without acknowledging or withdrawing his supplemental brief, the
Secretary argued that this case is controlled by Andrews and that the
appellant's theory cannot be considered because it can be properly raised
only through a motion asserting CUE in the 1986 RO decision, and no
argument based on CUE is before the Court. Thereafter, the appellant,
pursuant to Rule 30(b) of this Court's Rules of Practice and Procedure,
filed notices of supplemental authorities.

III. ANALYSIS
A. Issue Presented
The question presented to the Court is not whether the Secretary has
a duty to sympathetically read a pro se veteran's filings to determine
whether a claim has been raised. It is beyond question that the Secretary
has such a duty and that it applies not just to total disability based on
individual unemployability (TDIU) ratings, but also to any claim for
benefits. See Szemraj v. Principi, 357 F.3d 1370 (Fed. Cir. 2004). The
question presented to this Court is the proper procedural time and
mechanism to assert an alleged failure of the Secretary to perform this
duty. We begin with the proposition that as a Court we are reviewing
specific decisions below that have been appealed to us. See 38 U.S.C.
7252(a) (granting the Court jurisdiction "to review decisions of the Board
"). Thus, in order for this Court to have jurisdiction to review an
asserted error related to the failure to sympathetically read a claimant's
filings, the claimant on appeal here must be asserting that the error
occurred in the decision on appeal to the Court or that the error occurred
in a final decision presented in the context of a CUE motion.
In the context of this case, we must determine whether the arguments
raised on appeal are an improper attempt to use an appeal of the December
2003 Board decision [hereinafter "effective- date decision"] as a
collateral attack on the 1986 RO decision. See Cook v. Principi, 318 F.
3d 1334, 1337 (Fed. Cir. 2002) (en banc). In essence, we must
determine whether the 1986 RO decision decided a section 1151 claim, which
would now have to be the subject of a collateral attack, or whether the
alleged section 1151claim in 1986 was still pending at the time of the
appellant's 1992
correspondence and, therefore, is part of the present claim stream
including this direct review. If we determine that the 1986 RO decision
decided a section 1151 claim, then we do not have jurisdiction to review
the alleged error in that decision, as that decision is final and not part
of the claim presently on direct appeal. See DiCarlo v. Nicholson, 19
Vet.App. __, __, No. 03-629, slip op. at 8 (May 10, 2006) (once the
Secretary has made a finding of fact, a later decision reconsidering that
finding outside of a certain circumstances (e.g., outside the context of
CUE or reconsideration by the Board Chairman) is ultra vires and must be
set aside); Beverly v. Nicholson, 19 Vet.App. 394, 405 (2005) (whether a
sympathetic reading of filings raises a claim is a question of fact). If
we determine that any potential claim was still pending and part of the
claim stream that resulted in the Board decision on appeal, then we would
have jurisdiction to address the substance of the appellant's argument.
B. Previously Established Law
1. Effective-Date Decisions
Section 5110(a) of title 38, U.S. Code, governs the assignment of an
effective date for an award of benefits:
[T]he effective date of an award based on an original claim, a claim
reopened after final adjudication, or a claim for increase, of
compensation, dependency and indemnity compensation, or pension,
shall be fixed in accordance with the facts found, but shall not be
earlier than the date of receipt of application therefor.
38 U.S.C. 5110(a). The implementing regulation similarly states that
the effective date shall be the date of receipt of claim or date
entitlement arose, whichever is later, unless the claim is received within
one year after separation from service. See 38 C.F.R. 3.400 (2005).
A Board determination of the proper effective date for an award of VA
benefits is a finding of fact reviewed under the "clearly erroneous"
standard of review set forth in 38 U.S.C. 7261(a)(4). See Hanson v.
Brown, 9 Vet.App. 29, 32 (1996). "A factual finding 'is "clearly
erroneous" when although there is evidence to support it, the reviewing
court on the entire evidence is left with the definite and firm conviction
that a mistake has been committed.'" Hersey v. Derwinski, 2 Vet.App. 91,
94 (1992) (quoting United States v. U.S. Gypsum Co., 333 U.S. 364, 395 (
1948)). The Court may not substitute its judgment for the factual
determinations of the Board on issues of material fact merely because the
Court would have decided those issues differently in the first instance.
Id.
The Board is required to consider, and discuss in its decision, all "
potentially applicable" provisions of law and regulation. Schafrath v.
Derwinski, 1 Vet.App. 589, 593 (1991) (emphasis added); see 38 U.S.C.
7104(a); Weaver v. Principi, 14 Vet.App. 301, 302 (2001) (per curiam order
); Sanden v. Derwinski, 2 Vet.App. 97, 100 (1992). The Board is also
required to provide a written statement of the reasons or bases for its
findings and conclusions on all material issues of fact and law presented
on the record; the statement must be adequate to enable a claimant to
understand the precise basis for the Board's decision, as well as to
facilitate review in this Court. See 38 U.S.C. 7104(d)(1); Allday v.
Brown, 7 Vet.App. 517, 527 (1995); Gilbert v. Derwinski, 1 Vet.App. 49, 57 (
1990).
2. Pending Unadjudicated Claims
The Secretary defines a "pending claim" as "[a]n application, formal
or informal, which has not been finally adjudicated." 38 C.F.R. 3.160(c
) (2005). This definition predates the creation of this Court. See 38 C.
F.R. 3.160(c) (1988) (same as current version). Consistent with this
regulation, in several instances, this Court has held that a claim remains
pending-even for years-if the Secretary fails to act on a claim before him
. See, e.g., Norris, 12 Vet.App. at 422 (concluding that TDIU claim
reasonably raised in 1987 and 1989 remained pending at RO). Similarly, a
decision may be rendered nonfinal when "the time for appealing either an
RO or a Board decision did not run where the [Secretary] failed to
provide the veteran with information or material critical to the appellate
process." Cook, 318 F.3d at 1340 (discussing Tablazon, Hauck, Kuo, and
Ashley, all infra).
In Cook, the Federal Circuit observed that this Court has tolled the
period of time for a claimant to act after an RO decision, leaving the
case in a nonfinal status when the Secretary has failed (1) to notify a
claimant of the denial of a claim, see Hauck v. Brown, 6 Vet.App. 518, 519 (
1994), (2) to mail a claimant a copy of the Board decision pursuant to 38
U.S.C. 7104(e), see Ashley v. Derwinski, 2 Vet.App. 307, 311 (1992), (3)
to provide notice to the claimant of appellate rights, see In the Matter
of the Fee Agreement of Cox, 10 Vet.App. 361, 375 (1997), vacated on other
grounds, 149 F.3d 1360 (Fed. Cir. 1998), or (4) to issue the claimant an
SOC, see Tablazon v. Brown, 8 Vet.App. 359, 361 (1995); Kuo v. Derwinski,
2 Vet.App. 662, 666 (1992). All of these cases involved claims
that had been explicitly decided by an RO in the first instance.
Nonetheless, the essence of each case is that the time limitations
pertaining to a veteran's right to appeal an
adverse decision do not begin to run until the veteran has received
proper notice that his claim was denied.
In this line of cases, we have also held that a pending claim can be
addressed when a subsequent claim for the same disability is explicitly
adjudicated. In Myers v. Principi, 16 Vet.App. 228, 229 (2002), the
appellant's claim for service connection for a back condition was denied
in April 1958. Within one year of the mailing of notice of that decision,
the appellant submitted a letter to the RO that the Secretary failed to
recognize was an NOD as to that decision. Id. The RO subsequently denied
three requests to "reopen" the 1958 denial and the appellant did not
attempt to appeal them. Id. Finally, in 1994 the RO rejected another
attempt to "reopen" the claim and that decision was appealed to the Board.
Id. at 230. After a Board remand, the appellant was granted benefits and
he appealed the effective date assigned. Id. On review of the effective-
date decision, this Court held that the original 1958 RO decision never
became final because the NOD had not been processed, notwithstanding the
intermediate denials of the three claims to "reopen." Id. at 235. As a
result, the Board's 1997 decision was a continuation of the appeal that
began with the 1959 NOD and "the veteran's original service-connection
claim was part of the current claim stream." Id. at 236. The Court
remanded the matter to the Board to assign an appropriate effective date
based on his original claim. Id. Hence, under Myers, if a claim is left
pending, it can be addressed when a subsequent "claim" is processed
.
3. CUE Motions
A claim of CUE is a collateral attack on a final decision by an RO or
the Board. Disabled Am. Veterans v. Gober, 234 F.3d 682, 696-98 (Fed. Cir.
2000), cert. denied, 532 U.S. 973 (2001). Each theory of CUE is a
separate claim. Andre v. Principi, 301 F.3d 1354 (Fed. Cir. 2002) ("[E]
ach 'specific' assertion of CUE constitutes a claim that must be the
subject of a decision by the Board before the . . . Court [of Appeals for
Veterans Claims] can exercise jurisdiction over it."); Bradley v. Principi,
14 Vet.App. 255, 256-57 (2001) (per curiam order) (stating that "each [CUE]
theory alleged necessarily constitutes a separate claim").
The claimant must provide some degree of specificity as to what the
alleged error is and, unless it is the kind of error that, if true, would
be CUE on its face, "persuasive reasons must be given as to why the result
would have been manifestly different but for the alleged error." Fugo v.
Derwinski, 6 Vet.App. 40, 44 (1993); see also Bustos v. West, 179 F.3d
1378, 1380-81 (Fed. Cir. 1999) (adopting this Court's interpretation of 38
C.F.R. 3.105), cert. denied, 528 U.S. 967 (1999). To establish CUE in a
final decision of an RO or the Board, a claimant must show that (1) either
the correct facts known at the time were not before the adjudicator, or
that the law then in effect was incorrectly applied, and (2) had the error
not been made, the outcome would have been manifestly different. Grover v.
West, 12 Vet.App. 109, 112 (1999). A mere disagreement with how the facts
were weighed or evaluated is not enough to substantiate a CUE claim.
Damrel v. Brown, 6 Vet.App. 242, 246 (1994). Nor does CUE include the
otherwise correct application of a statute or regulation where, subsequent
to the decision challenged, there has been a change in the interpretation
of the statute or regulation. Jordan (Timothy) v. Nicholson, 401 F.3d
1296, 1298-99 (Fed. Cir. 2005); 38 C.F.R. 20.1403(e) (2005). Moreover,
the failure to address a specific regulatory provision involves harmless
error unless it is shown that the outcome would have been "manifestly
different." Fugo, 6 Vet.App. at 44. "Silence in a final RO decision made
before February 1990 cannot be taken as showing a failure to consider
evidence of record." Eddy v. Brown, 9 Vet.App. 52, 58 (1996).
C. Theories of the Case
1. Appellant's Theory: The effective-date decision incorrectly
identified the claim that was granted.
The essence of the appellant's theory is that the Board decision
presently on appeal to the Court erred during the assignment of his
effective date when the Secretary incorrectly identified which of his
submissions was the claim that led to the award of benefits. He maintains
that the April 1992 document that the Secretary identifies as the relevant
claim under section 5110 was not a new claim but merely correspondence
pertaining to the pending and unadjudicated May 1986 claim. This theory
draws support from 38 C.F.R. 3.160(c), Myers, and the numerous decisions
that hold when an appellant submits a claim or takes an action on a claim
that puts the ball into the Secretary's court, it remains there-possibly
for years-until the Secretary takes appropriate action to return the onus
to the claimant to act within the time periods specified by statute and
regulation. See Tablazon, Hauck, Kuo, and Ashley, all supra.
2. Secretary's Theory: The 1986 RO decision sub silentio denied the
appellant's section 1151 claim.
The essence of the Secretary's theory is that even if the May 1986
application raised a claim under section 1151, the August 14, 1986, RO
decision that denied non-service-connected pension
benefits also denied the section 1151 claim sub silentio. Accordingly,
there was no claim pending prior to 1992 and the proper procedure for
raising the issue is for the appellant to file a motion asserting CUE in
the 1986 RO decision. As no such motion has been filed or decided by the
Board, the Secretary argues that this Court lacks jurisdiction to consider
the appellant's theory of error as part of a direct review of the decision
that assigned an effective date to the appellant's 1992 claim. The
Secretary draws support for this theory from the Federal Circuit's
statement in Andrews: "when the VA violates Roberson by failing to
construe the veteran' s pleadings to raise a claim, such claim is not
considered unadjudicated but the error is instead properly corrected
through a CUE motion." 421 F.3d at 1284. In essence, the Secretary is
asserting that the appellant's attempt to raise the alleged error in this
separate proceeding is an unauthorized collateral attack outside the scope
of those permitted by Congress. See Cook, 318 F.3d at 1341 (overruling
the decision in Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999), that "grave
procedural error" prevents a decision of the Secretary from becoming final).
3. The Conflict Between the Theories
The two theories outlined above cannot coexist because they are based
on inconsistent factual premises. The first theory relies on the
proposition that there was no decision on the alleged 1986 section 1151
claim while the second theory relies on the 1986 RO decision as a final
decision on a section 1151 claim, which decision must be challenged for
CUE. In other words, either the appellant in this case is trying to
bypass the congressionally-authorized procedures for collaterally
attacking the final 1986 RO decision or the Secretary is incorrect to
assert that the appellant must attempt to collaterally attack a decision
that is irrelevant to the alleged section 1151 claim that was pending
under 3.160(c) until 1992 and is now on direct appeal.
Accordingly, the question presented is: Assuming a claim has been
reasonably raised by a claimant, is that claim denied sub silentio by an
RO decision that should have adjudicated it, or does that claim remain
pending under 3.160(c) and Myers until it is explicitly adjudicated?
D. Resolving the Conflict
For the reasons listed below, we conclude that a reasonably raised
claim remains pending until there is an explicit adjudication of the claim
or an explicit adjudication of a subsequent "claim" for the same
disability. See Myers and 38 C.F.R. 3.160(c), both supra. If there is
no explicit final
denial of the original claim prior to the granting of the subsequent
claim, then, as part of his or her appeal of the effective-date decision,
an appellant can raise the fact that he or she filed the original claim
for the same disability at an earlier date than the claim which was
subsequently granted.
We begin by looking at the crux of the problem: the apparent
inconsistency between Norris and Andrews. At oral argument, the Secretary
asserted that Andrews had overruled Norris. Based on the analysis below,
the Court disagrees. While those decisions discuss related concepts, they
are factually distinguishable from each other and from the other relevant
decisions in this area.
Norris is the first of the decisions at issue. In Norris, the
appellant filed a claim for an anxiety disorder. 12 Vet.App. at 414. The
claim was granted and he was assigned a schedular rating and an effective
date. Id. Two later decisions of the Board (in 1980 and 1985) granted an
increased schedular rating and denied a TDIU rating. Id. Following those
decisions, the appellant underwent numerous hospitalizations, each of
which resulted in an RO decision that awarded the appellant a temporary
total disability rating for the period of his hospitalization and "
continued" his 70% schedular rating thereafter. Id. at 415-16. The
evidence at the time of the RO decisions from June 1987 included evidence
of unemployability. Id. However, the issue of TDIU was not considered or
decided by the RO. After the RO decisions became final, the appellant
filed a motion to revise the June 1987 and February 1989 RO decisions on
the basis of CUE because they failed to adjudicate TDIU. Id. at 416.
The Court determined that where, as in Norris, the claimant has
already been granted service connection for a disability and has a
schedular rating that meets the minimum criteria of 38 C.F.R. 4.16(a) (i.
e., he had at least a 60% rating for his psychiatric disorder) and a VA
examination report indicated unemployability due to that disability, the
claimant has made an informal claim for a rating increase, to include an
evaluation as to a TDIU rating, and VA must adjudicate TDIU. Id. at 420-
21. The Court concluded that such an informal claim had been raised: "We
now hold as a matter of law that a TDIU claim was reasonably raised to the
RO and was not adjudicated. Thus, there is no final RO decision on this
claim that can be subject to a CUE attack." Id. at 422. We note that
Norris held that the TDIU claims reasonably raised in 1987 and 1989
remained pending at the RO, and did not reach the issue of the ultimate
fate of the appellant's claim. The holding of Norris was "the Board
decision determining that CUE was not committed in [the] 1987 and 1989 RO
decisions is
AFFIRMED for the reasons that are contained herein." Id. (capitalization
in original). The practical conclusion of Norris was that, following the
VA medical examination that was conducted to determine whether the
veteran's condition had improved in order to determine whether the
assigned disability rating should be decreased or continued, the 1987 and
1989 RO decisions did not adjudicate the informal claims for a TDIU rating
raised by that evidence when they "continued" or "resumed" the previously
awarded 70% rating after the hospitalization. Id. at 415-16.
By comparison, in Andrews, the appellant was granted service
connection and assigned a disability rating for post-traumatic stress
disorder (PTSD) in a 1983 RO decision. 421 F.3d at 1280. Although there
was evidence that the appellant was unemployable, the RO did not decide
whether the appellant was entitled to TDIU. Id. Similarly a 1985 RO
decision increasing the appellant's disability rating did not consider
whether the appellant was entitled to a TDIU rating. Id. In 1995, the
appellant filed a motion asserting CUE in the 1983 and 1985 decisions for
failing to apply correctly the disability schedule. Id. "At no time [in
the proceedings before the Secretary] did [the appellant] argue that the
RO in 1983 or 1985 had erred in failing to consider Andrews as having
raised a TDIU claim." Id.
The Secretary argued to the Federal Circuit "that, even if the VA had
erred in failing to construe the veteran's pleadings to raise a TDIU claim
in the 1983 and 1985 proceedings, such an error should not be considered
on a CUE motion. Rather, the government urges that the TDIU claim is
still pending before the RO awaiting adjudication, and that the Veterans
Court and this court are without jurisdiction because there is no Board
decision for us to review." Id. at 1281. The Federal Circuit replied: "
We disagree; the government's position is contradicted by our decision in
Roberson. . . . [W]e clearly held in Roberson that the VA's failure to
consider a TDIU claim in this manner is properly challenged through a CUE
motion." Id. Nonetheless, the Federal Circuit in Andrews concluded that
the appellant had not asserted the potential TDIU claim to the Board as a
basis for finding CUE in the 1983 and 1985 RO decisions. Id. at 1284. As
the only CUE theory asserted to the Board was an error in the schedular
rating assigned, the TDIU theory of CUE was not reviewable until properly
presented to and decided by the Board. Id.
Andrews relies on the Federal Circuit's decision in Roberson, which
also involved a TDIU claim. Roberson stated that Norris "is both on-point
and informative." 251 F.3d at 1383. The
Federal Circuit further stated that "[t]he facts of Norris are similar to
the present case" (both appellants received 70% disability ratings for a
mental disorder) but concluded that "the facts of Norris are
distinguishable from [the appellant's] situation" because in Norris
informal claims, which were found to raise TDIU, were made subsequent to
the initial rating determination whereas in Roberson TDIU was found to
have been raised as part of the initial claim for service connection (i.e.,
assertion of unemployability made prior to the initial RO decision that
granted service connection and awarded a rating). Id. After concluding
that the cases were factually distinguishable, Roberson went on to say:
Unlike Norris, Roberson's original medical disability claim was
decided by the RO and is the claim for which Roberson seeks the
highest rating possible. Ratings decisions by the DVA are deemed "
final and binding . . . as to conclusions based on the evidence on
file at the time the [DVA] issues written notification of the
decision." 38 C.F.R. 3104(a) (1994). But see Hayre v. West, 188 F.
3d 1327, 1333 (Fed. Cir. 1999) ("[a] breach of duty to assist in
which the VA failed to obtain pertinent [evidence] specifically
requested by the claimant and failed to provide the claimant with
notice explaining the deficiency is a procedural error ... that
vitiates the finality of an RO decision for purposes of a direct
appeal"). Roberson has not alleged that the VA failed to obtain
pertinent evidence. Thus, Roberson's claim has been finally decided
by the RO.
251 F.3d at 1383-84 (emphasis added). Accordingly, Roberson expressly
considered and did not overrule Norris. Rather, it found TDIU had been
denied by the RO decision on the appellant's initial disability rating
after he had requested "the highest rating possible" disability rating.
There is no suggestion in Roberson that a decision on a wholly different
claim could be regarded as a final decision on a claim not mentioned in
that decision. Rather Roberson was narrowly written to leave the "on-
point and informative" decision in Norris intact. Roberson, 251 F.3d at
1383.
The Andrews court did not disagree with Norris, and its decision
stated only that a claimant must raise the issue of an alleged failure to
address TDIU through a collateral attack, such as a motion for revision
based on CUE, when evidence regarding TDIU was before the RO prior to its
decision on a claim that sought a schedular rating and that schedular
rating decision was not directly appealed. See DiCarlo, 19 Vet.App. at __,
slip op at 5-7 (discussing the types of collateral attack authorized to
challenge a decision by the Secretary). None of these decisions, however,
suggests that it is possible for an RO decision on one claim to be
regarded as a denial of a wholly different claim. Hence, Andrews held,
based on the facts presented, that a collateral attack must be used when,
as in
Roberson, a TDIU rating is not addressed as part of a decision on a claim
that sought a schedular rating and that schedular rating decision is not
directly appealed.
This interpretation of Norris, Roberson, and Andrews is consistent
with the other decisions of the Federal Circuit in this area. Twelve days
after Andrews was decided, the Federal Circuit said in Bingham "as we
recently held in Andrews v. Nicholson, 421 F.3d 1278 (Fed. Cir. 2005), the
VA's failure to consider all aspects of a claim does not render its
decision non-final but instead 'is properly challenged through a CUE
motion.'" 421 F.3d at 1349 (emphasis added). Bingham applied this
principle to hold that a decision that denied service connection for
hearing loss was a final decision as to every theory of entitlement for
that benefit, including theories of presumptive service connection. Id.
at 1348-49. Specifically, the Federal Circuit in Bingham held that a 1950
Board decision denying the appellant's claim for hearing loss was a final
decision on every theory under which that benefit could be granted. Id.
Therefore, even if the Board failed to consider the possibility of
presumptive service connection when it denied direct service connection,
the appellant did not have a pending claim for service connection on a
presumptive basis because that was a different theory, not a different
claim. We specifically note that Bingham did not suggest that the
Secretary's failure to decide a reasonably raised claim could not lead to
a pending and unadjudicated claim.
In addition to Bingham's interpretation of Andrews and Andrews'
reliance on Roberson, we note that the Federal Circuit has issued two
other major cases discussing the Secretary's duty to sympathetically read
a veteran's pleadings in determining whether an informal claim was raised.
We find Moody v. Principi, 360 F.3d 1306 (Fed. Cir. 2004), instructive.
In Moody, a 1996 RO decision granted TDIU and assigned a 1994 effective
date because, according to the RO, that was the first time he claimed that
his psychiatric disorder was secondary to his service-connected
prostatitis. 360 F.3d at 1309. In 1998, he filed a CUE motion as to the
1996 effective-date decision-he argued that it was CUE not to find an
earlier informal claim for secondary service connection based on his prior
benefits claims and the evidence in the record at the time. Id. The
Board rigorously applied the 38 C.F.R. 3.155 (2005) informal claim
regulation in assessing whether there was an earlier claim and rejected
his CUE motion, and, on appeal to the Court, the appellant argued for a
remand for the Board to consider Roberson. The Federal Circuit held that "[
t]he question is whether the
B[oard], as required by Roberson, sympathetically read Mr. Moody's
filings prior to June 24, 1994, in determining whether Mr. Moody made an
informal claim for secondary service connection for his psychiatric
disorder." Moody, 360 F.3d at 1310. Based on this ruling, the Federal
Circuit remanded the matter to address, using the correct legal standard
set forth in Roberson, the factual issue of whether a claim had been
raised. Id. To be clear, while Moody did involve a CUE motion, it was a
CUE motion that asserted error in the effective-date decision, not in a
decision that allegedly denied the claim sub silentio. Accordingly, Moody
also supports the proposition that raising a pending unadjudicated claim
theory in connection with a challenge to the effective-date decision is
procedurally proper.
We also note the Federal Circuit's decision in Szemraj v. Principi,
supra, does not favor a particular theory or procedure for dealing with
unadjudicated claims. In Szemraj, the appellant alleged CUE in a 1989
Board decision that denied service connection for a psychosis in service.
The theory of the CUE motion was that the 1989 Board decision "failed to
apply the one-year post- service presumption of service connection
provided by 38 C.F.R. 3.307 and 3.309" when it denied his psychosis
claim. Szemraj, 357 F.3d at 1372. Our decision held that the Roberson
duty to sympathetically read the pleadings of a veteran did not apply to
CUE motions. Szemraj, 357 F.3d at 1373. The Federal Circuit reversed
this legal conclusion and held that "VA has a duty to sympathetically read
a veteran's allegations in all benefit claims." Id. However, the Federal
Circuit went on to clarify:
[A]part from the requirement that a pro se veteran's pleadings be
read sympathetically, our decision in Roberson did not change the
well-established legal standard for determining the existence of CUE
in RO and BVA decisions. See Cook, 318 F.3d at 1344. . . . In Cook
we held en banc that in order to constitute CUE, the alleged error
must be both "outcome determinative" and "based upon the evidence of
record at the time of the original decision. 318 F.3d at 1344. . . .
Contrary to the appellant's argument, Roberson does not require VA to
reconcile the conflicting evidence before adjudication, nor does it
require the agency to develop evidence on the veteran's theory. To
construe Roberson as requiring factual development as a matter of
course would be to effectively overrule our decision in Cook that the
failure to assist in developing the evidentiary record cannot
constitute CUE. See id.
Szemraj, 357 F.3d at 1375-76 (emphasis added). The Federal Circuit then
affirmed the outcome of this Court's decision after concluding that our
legal error was harmless because the appellant had not
actually made an allegation that the Secretary had failed to give a
sympathetic reading to his pleadings in the decision that allegedly
contained CUE.
Szemraj is distinguishable from this case because the CUE motion on
appeal was attacking a prior decision that explicitly denied the claim at
issue. The original decision denied a claim for service connection for
psychosis and the CUE motion asserted that the denial of service
connection for psychosis was in error because it failed to consider a
specific theory of entitlement. Szemraj, 357 F.3d at 1372. Szemraj did
not involve the failure to adjudicate a separate claim that had been
reasonably raised and nothing in Szemraj speaks to the appropriate theory
or procedure to employ when the Secretary fails to adjudicate an entirely
separate claim. Szemraj stands only for the proposition that the duty to
sympathetically read a veteran's pleadings also applies to those pleadings
that assert CUE.
Additionally, we note that the Federal Circuit's en banc decision in
Cook endorsed our pending claim case law. As discussed in Part III.B.2.,
supra, the en banc Federal Circuit in Cook favorably reviewed our
decisions in Tablazon, Hauck, Kuo, and Ashley and endorsed our holdings
that a procedural default clock does not run while the ball is in the
Secretary's court. 318 F.3d at 1340. In overruling the holding in Hayre
that "grave procedural error" would prevent a decision of the Secretary
from becoming final, see Hayre, 188 F.3d at 1333, the en banc Federal
Circuit in Cook concluded that our case law on pending claims was
distinguishable. The en banc Federal Circuit concluded that the appellant
in Hayre-in spite of any "grave procedural error"-had received notice of
the adjudication and an opportunity to appeal. Cook, 318 F.3d at 1341.
Whereas, our pending claim case law illustrated situations where the
appellant had been denied his appellate rights. Id.
If we were to accept the Secretary's invitation to read Andrews
broadly as endorsing a general doctrine of sub silentio denial, we would
run afoul of this distinction recognized in Cook. It is reasonable to say
that an appellant who receives a disability rating that is less than 100%
has notice of how his condition has been rated and the opportunity to
appeal the rating decision. Even if he does not have a clear
understanding of the TDIU aspect of a rating decision, he does have a
clear statement of which disability is being rated and the fact that the
Secretary has declared it to be less than 100% disabling. Hence, an
appellant's ignorance of a particular legal theory for a higher rating
does not preclude him from understanding that an appealable decision has
been made concerning
his claim. However, by urging us to adopt a doctrine of general sub
silentio denials, the Secretary is suggesting in this case that the denial
of a non-service-connected pension claim in 1986 gave the appellant in
this case adequate notice and opportunity to appeal the 1986 RO decision
as to a section 1151 claim. This suggestion goes too far. A section 1151
claim, which treats a disability as if it were service-connected, is in no
way an aspect of a claim for a non-service-connected pension.
Reading Andrews as broadly as the Secretary suggests would run afoul
of the due process concerns voiced by the en banc Federal Circuit in Cook
and by this Court in Thurber v. Brown, 5 Vet.App. 119, 123 (1993), where
we noted that "VA's nonadversarial claims system is predicated upon a
structure which provides for notice and an opportunity to be heard at
virtually every step in the process." See 38 U.S.C. 5104(a) (
requiring the Secretary, when making a decision affecting the provision of
benefits to a claimant, to "provide to the claimant . . . notice of such
decision"), 5104(b) (requiring the Secretary, when denying a benefit
sought, to provide a statement of the reasons for the decision and a
summary of the evidence considered); 38 C.F.R. 3.103(b) (2005) ("
Claimants and their representatives are entitled to notice of any decision
made by VA affecting the payment of benefits or the granting of relief.").
Given that Andrews gave no consideration as to the profound consequences
of adopting a general doctrine of sub silentio denials, we do not think it
appropriate to suggest that it meant to cast doubt on the Federal
Circuit's decision in Cook.
Aside from the support we find in prior case law, the pending-
unadjudicated-claim theory is clearly a preferable approach to
administering the veterans benefits system. Treating the Secretary's
failure to sympathetically read and adjudicate a reasonably raised claim
as a pending claim benefits veterans because it protects their appellate
rights and works no hardship on the Secretary in that it requires only
that each claim be specifically addressed. If a veteran is aware of a
particular benefit and makes an unambiguous claim for it, the Secretary's
duty to sympathetically read his submissions is irrelevant. That duty
primarily helps those veterans who have not clearly articulated that they
are seeking a particular benefit. It is illogical to expect such veterans
to immediately recognize when the Secretary has failed to adjudicate a
reasonably raised claim because it is ignorance of the intricacies of
potential claims that makes the duty necessary. Hence, if the law equates
a VA failure to adjudicate a reasonably raised claim to a sub silentio
denial of the claim, then it is unlikely that the veteran would have
sufficient notice of the disposition of his claim to assert
error on direct appeal. Instead, any error in the adjudication of that
claim would have to be raised in a CUE motion. See 38 C.F.R. 20.1403(c) (
2005) (defining CUE as "a very specific and rare kind of error. It is the
kind of error, of fact or of law, that when called to the attention of
later reviewers compels the conclusion, to which reasonable minds could
not differ, that the result would have been manifestly different but for
the error"); see also Moody, supra.
Moreover, even a savvy veteran may not be aware that there is a
disagreement as to which document raised a claim until after an effective
date is assigned. Veterans benefits litigation is frequently piecemeal.
A veteran will submit a continuous stream of evidence and correspondence.
Rather than holding all the claims until every one is ready to be decided,
the Secretary will develop and decide multiple claims separately-often
over a period of years. A savvy veteran could easily submit what he
believes to be a claim and receive from the Secretary an adjudication of a
previously raised claim for the same disability. The veteran could then
submit more correspondence on the claim he was trying to raise and receive
a request from the Secretary for evidence or to report for an examination.
There could be years of intervening appeals, remands, and revised
decisions before the claim is actually granted and the assignment of the
effective date reveals that the Secretary did not recognize the initial
submission as a claim for the benefit. In the meantime, the decision that
sub silentio denied the claim that the appellant alleges was reasonably
raised has become final and can only be challenged for CUE. Once again,
the veteran would have been denied direct review of the sub silentio
denial because he had no reason to know that was an issue at the time he
could have appealed that decision. Accordingly, accepting a doctrine of
sub silentio denials has grave implications for due process and protecting
the appellate rights of veterans.
Of course, not every claim for a benefit will be granted.
Accordingly, if a claim is denied, it is often irrelevant when it was
first raised. There does not need to be any decision on the issue of when
the claim was first raised unless and until it actually becomes relevant
to an award of benefits. If a claim is granted, however, the date the
claim was first raised is relevant to determining the effective date.
Under Myers, the appellant can argue that an earlier claim for the
benefits should be considered part of the same claim stream that
eventually resulted in the award of benefits for the purpose of
establishing the effective date. If a veteran believes that he has a
pending claim for a benefit that has not received an initial decision, the
veteran can unambiguously inform the Secretary
that a particular benefit is being sought. The Secretary must then
decide entitlement to the benefit and-if relevant-address the issue of
when the claim was first raised. See DiCarlo, 19 Vet.App. at __, slip op.
at 7 (holding that the finality of a specific claim is an issue that can
be raised when relevant, but is not a procedure or claim in and of itself
).
This is not to say that the question of when a claim was raised will
never be relevant before an effective date is assigned. It may be
relevant, for example, to determining which version or versions of the law
are relevant to the substantive question of entitlement. See Rodriguez v.
Nicholson, 19 Vet.App. 275, 288-89 (2005) (discussing considerations
relevant to determining which version of a statute or regulation should
apply when there is a change during the pendency of a case). However, it
makes little sense to adjudicate the issue of when a claim was raised
unless that issue will have some practical effect. In many cases,
deciding whether or not a claim was reasonably raised below on the
possibility that it might be relevant to a future effective-date
determination amounts to nothing more than an advisory opinion. See
Waterhouse v. Principi, 3 Vet.App. 473, 474 (1992) (the Court does not
issue advisory opinions); cf. Mintz v. Brown, 6 Vet.App. 277, 281, 283 (
1994) (Board lacked jurisdiction to entertain appellant's claim where he
was seeking an advisory opinion).
Finally, we do not hold that the Secretary's failure to adjudicate a
reasonably raised claim can never be the basis for a CUE motion. Rather
it can be the basis of a CUE motion as to a final decision of the
Secretary where the issue was relevant to a decision actually made. As
discussed above, Moody is a good example. Because the effective-date
decision in that case had become final, the appellant properly alleged CUE
in the effective-date decision on the theory that it failed to correctly
identify which document was the appellant's claim for purposes of
assigning an effective date under section 5110. The appellant's theory in
this case is no different from the theory of the appellant in Moody. The
only difference is that, as a matter of procedure, the appellant here has
directly appealed his effective-date decision rather than allowing it to
become final. See Beverly, 19 Vet.App. at 406 ("It would be illogical and
unfair to require the appellant to wait until the Board decision is final
and then face the high burden of proving CUE when any other error can be
addressed immediately and more favorably when raised in a timely manner.")
Based on the above, we conclude that the Federal Circuit has neither
overruled the pending- unadjudicated-claim doctrine articulated in Norris
nor created a general doctrine of sub silentio denials. Therefore, the
appellant is correct that we have jurisdiction over his appeal because it
is not a collateral attack on a prior final RO or Board decision.
E. Application of Law to Fact
Now that we are satisfied that the appellant is properly raising his
assertion of error against the effective-date decision, we must review the
Board's findings and conclusions below. The Board reviewed the 1986
filings and found that nothing in the four corners of either document
could be construed as an intent to claim section 1151 benefits R. at 8-9.
The Board focused on whether the appellant had alleged negligence or a
lack of proper skill on the part of the VA physicians and whether he had
expressed an intent to apply for section 1151 benefits. R. at 8-9. Both
of these forms of analysis were legally incorrect. As the Federal Circuit
explained in Hodge v. West, 155 F.3d 1356, 1362-63 (Fed. Cir. 1998), when
it announced the sympathetic-reading requirement based on the legislative
history of the Veterans' Judicial Review Act and Veterans' Benefits
Improvement Act of 1988, Congress intended to preserve the nonadversarial
nature of the VA system wherein the Secretary provides claimants with
assistance in submitting and substantiating claims. Although there is no
statutory or regulatory definition of "sympathetic reading," it is clear
from the purpose of the doctrine that it includes a duty to apply some
level of expertise in reading documents to recognize the existence of
possible claims that an unsophisticated pro se claimant would not be
expected to be able to articulate clearly. Cf. Andrews, 421 F.3d at 1283 (
holding that the duty to sympathetically read submissions does not apply
to pleadings through counsel).
As to the Board's suggestion that the appellant was required to
allege negligence or lack of skill, measuring the appellant's submissions
against a strict pleading requirement is fundamentally inconsistent with
the concept of a sympathetic reading and, therefore, constituted legal
error by the Board. The application of such a pleading requirement
violates the duty to sympathetically read submissions because it required
the appellant to demonstrate a level of sophistication that would render
moot the duty to sympathetically read his pleadings. In other words, it
is precisely because unsophisticated claimants cannot be presumed to know
the law and plead claims based on legal elements that the Secretary must
look at the conditions stated and the causes averred in a pro se
pleading to determine whether they reasonably suggest the possibility of
a claim for a benefit under title 38, regardless of whether the appellant
demonstrates an understanding that such a benefit exists or of the
technical elements of such a claim. The Board's suggestion that the
appellant was required to articulate a specific intent to "claim . . .
compensation benefits under the provisions of 38 U.S.C.A. 1151" is
similarly flawed. R. at 8, 9. The duty to sympathetically read exists
because a pro se claimant is not presumed to know the contents of title 38 or to be able to identify the specific legal provisions that would entitle him to compensation. Again, there would be no need for the duty to sympathetically read pleadings if pro se claimants had encyclopedic knowledge of veterans law.
Finally, we hold that it was also error for the Board to suggest that
it was limiting the material being reviewed to the "four corners" of the application and the statement in support of the claim. Cf. EF v.
Derwinski, 1 Vet.App. 324, 326 (1991) (holding that VA's duty to give a liberal reading to an appeal of an RO decision applies to "all documents or oral testimony submitted prior to the B[oard] decision"). While it is not clear in the record that there were any other submissions by the appellant in connection with his 1986 application, the Board's articulation of a "four corners" standard for reviewing the appellant's pleadings is overly formal in a system where the Secretary must take a sympathetic view of an appellant's pleadings to determine whether a claim has been made.
In summary, a sympathetic reading of the appellant's pleadings cannot be based on a standard that requires legal sophistication beyond that which can be expected of a lay claimant and must consider whether the appellant's submissions, considered in toto, have articulated a claim. In
this case, it is premature for us to determine whether the Board's finding
was clearly erroneous because its denial was based on the application of
overly strict requirements that were inconsistent with the Secretary's
duty to sympathetically read pro se pleadings. Although we need not
formulate a specific standard at this time, we note that the duty to
sympathetically read must be based on reasonable expectations of a pro se
claimant and the Secretary. It is the pro se claimant who knows what
symptoms he is experiencing that are causing him disability, see Cintron v.
West, 13 Vet.App. 251, 259 (1999) ("[c]ertainly, the RO had no obligation
to read the mind[] of the veteran"), and may assert potential causes of
the disability even if he is not competent to make a medical diagnosis,
see Espiritu v. Derwinski, 2 Vet.App. 492, 494 (1992) (holding that lay
person is not competent to offer
evidence that requires medical knowledge). On the other hand, it is the
Secretary who knows the provisions of title 38 and can evaluate whether
there is potential under the law to compensate an averred disability based
on a sympathetic reading of the material in a pro se submission.
On remand, the Secretary must consider whether the May 8, 1986,
application and the appellant's submissions in support of that application
raised a claim for benefits under section 1151 based on a sympathetic
reading of those documents that does not require conformance with legal
pleading requirements or intent to seek benefits under section 1151
explicitly. In addition, such consideration must be undertaken in
accordance with regulations, law, and provisions in the VA Adjudication
Procedure Manual that may be applicable to his 1986 filings, see, e.g., 38
C.F.R. 3.151 (1985 & 2005) ("claim . . . for pension may be considered
to be claim for compensation"); 3.155 (1985 & 2005) (discussing informal
claim); VA Adjudication Procedure Manual (M21-1), para. 21.01(a) (1983-
1990) ("VA Form 21-526, Veterans Application for Compensation or Pension") (
VA to consider "VA Form 21-526 properly completed as to items 1 through 40
and signed by the veteran in item 42" as "a claim for either disability
compensation or pension, or both, depending upon the manner of preparation
and intent of the claimant, as provided below"); M21-1, Part III, para. 2.02(a) (2005) (essentially same as above but without reference to item numbers on Form 21- 526); M21-1, para. 21.01(d) (1983-1990) ("Combined Claim for Compensation and Pension") ("If the information specified" in both subparagraphs b (regarding claims for compensation) and c (regarding claim for pension) above is furnished, VA is to consider it "a claim for both benefits," and "[i]f there is any doubt as to which benefits is sought," VA is to adjudicate "both phases of the claim"); M21-1, Part III, para. 2.02(d) (2005) (essentially same). If the Board concludes that such a claim was raised, it must decide whether that claim was ever adjudicated or whether it was still pending at the time of the April 15, 1992, correspondence from the veteran. Based on its factual findings, the Board must address whether the appellant is entitled to an effective date earlier than April 15, 1992, for the grant of benefits under section 1151.

IV. CONCLUSION
Accordingly, the December 12, 2003, Board decision is VACATED and the matter is REMANDED for further proceedings consistent with this opinion.