RECORD OF PROCEEDINGS AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS IN THE MATTER OF: DOCKET NUMBER: BC-2014-02977 COUNSEL: NONE HEARING DESIRED: NO APPLICANT REQUESTS THAT: His claim under the Traumatic Servicemembers’ Group Life Insurance (TSGLI) Protection be approved. APPLICANT CONTENDS THAT: His TSGLI claim for Activities of Daily Living (ADL), from 1 Mar through 6 May 13 was denied by the reviewing physician, due to incomplete evidence by the orthopedic specialist and personal opinion. His appeal, which included ADL specific documentation from two medical specialist and a sworn statement from his caregiver, was denied for completely different reasoning, including, “ADL capability is not provided by Occupational Therapy or Physical Therapy” which is not a requirement for TSGLI documentation. The applicant’s complete submission, with attachments, is at Exhibit A. STATEMENT OF FACTS: According to AF IMT 348, Line of Duty Determination, the applicant was involved in a mid-air free fall collision with another jumper during a military free fall jump on 1 Mar 13 at Phillips Drop Zone, Yuma Proving Grounds, AZ. His collision resulted in a fractured Left Knee (Left Tibial Plateau/Left Fibular Head). He was immediately treated and transported to the Yuma Proving Ground Medical Clinic for initial evaluation and then to Yuma Regional Medical Center Emergency Room for Computerized Tomography (CT) scan. One week later after a Magnetic Resonance Imaging (MRI), it was found that he also had involvement of his ligaments inside the knee Posterior Cruciate Ligament (PCL). On 28 Apr 14, the applicant was medically retired with a compensable disability rating of 60 percent and was credited with 9 years, 4 months, and 14 days of active service for retirement. AIR FORCE EVALUATION: AFPC/DPFC recommends denial indicating based on eligibility criteria outlined in CFR Title 38 9.20 and Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and Tsunami Relief, 2005 (Public Law 109-13), the applicant’s TSGLI claim does not meet the TSGLI eligibility criteria for payment of ADL loss for 60 consecutive days or lessor payment threshold. On 19 Jan 15, DPFC received the applicant's application requesting that his TSGLI claim be approved. The burden of proof is on him to demonstrate that he suffered a scheduled loss (in this case, inability to perform two of six ADLs for at least 30 consecutive days). After reviewing the original claim and appeal, their position remains firm that the applicant does not meet TSGLI criterion for ADL loss for any payable threshold. Neither the original claim nor the appeal was arbitrarily denied. Two experienced physicians, trained by the Department of Veterans Affairs (DVA) on TSGLI loss criteria, reviewed the claim and medical records and determined the applicant did not meet TSGLI criterion for ADL loss. As stated by the physician that perform the appeal package assessment, "while it is reasonable that the applicant’s completion of ADLs would certainly be easier, faster, and more confident with assistance; it does not follow that this injury would have rendered him incapable of performing ADLs." It is also noted that the original claim's medical assessment indicated that the bathing ADL met TSGLI loss criteria; however, common sense dictates that ADLs of dressing and transferring could be performed without assistance by 25 Mar 13 when he was allowed to start working on range of motion exercises by taking the knee brace off (dressing could be done with the brace off). It is also logical to conclude that an able bodied (with the exception of the left lower extremity) person would be able to get in and out of a bed or chair using crutches alone (i.e., performing the transferring ADL). In fact, his physician states that he only required assistance with the toileting ADL for the first seven days. The toileting ADL includes aspects of the dressing and transferring ADLs. The complete DPFC evaluation is at Exhibit C. APPLICANT'S REVIEW OF AIR FORCE EVALUATION: The applicant refutes virtually every point made by the OPR and argues that based on the evaluation by his treating physician and his orthopedic specialist, his denial of TSGLI claim should be approved. He believes the reviewing physicians consistently ignore the stand-by assistance definition which states, “a patient requires someone to be within arm’s reach because the patient’s ability fluctuates and physical or verbal assistance may be needed.” The two medical providers have described all of his ADL losses in detail. He believes the advisory statement about the incident completely downplays the extreme nature of the accident by stating that he was “able to land.” In para 3, the advisory, simply put, calls his flight surgeon a liar and says that his notes were “exaggerated or just not based in reality.” His physician, is assigned to roughly 60 free fall instructors and understands the circumstances and the fact that the advisory attacks his integrity is offensive and has no place in this review. The applicant goes on to express his disagreement with some of the statements in the advisory opinion and the training and experience it took to become an Air Force Combat Controller. He has served his country and appeals to the Board to approve his claim. The applicant’s complete response, with attachments, is at Exhibit E. THE BOARD CONCLUDES THAT: 1. The applicant has exhausted all remedies provided by existing law or regulations. 2. The application was timely filed. 3. Sufficient relevant evidence has been presented to demonstrate the existence of error or injustice warranting corrective action. We note DPFC states that the medical consensus was he did not require the assistance of another person to perform the cited ADLs for 60 consecutive days or lessor payment threshold; however, we find a preponderance of the evidence supports a 30-day period. In this respect we note the applicant provides statements from two medical providers and his caregiver that discusses the specific limitations the applicant actually experienced and states the applicant indeed employed human assistance to perform the various ADLs (bathing, dressing and transferring) for 30 consecutive days or more. Moreover, it is our opinion that the nature of the applicant’s injury, the physical profile limitations and the short duration of his hospital stay more likely than not prevented his physicians and occupational therapist from fully observing the daily care and assistance the applicant required in performing the various ADLs. As such, we find the nature of the applicant’s injury, the physical profile limitations and the short duration of his hospital stay coupled with the caregiver’s first-hand account of the assistance she provided sufficient to grant TSGLI for 30 days. Therefore, we recommend the applicant’s records be corrected as indicated below. THE BOARD RECOMMENDS THAT: The pertinent military records of the Department of the Air Force relating to the APPLICANT be corrected to show that his application for Traumatic Servicemembers’ Group Life Insurance (TSGLI) Protection was approved based on the determination that he suffered the loss of three Activities of Daily Living (ADL) for 30 days and he is entitled to payment in the amount of $25,000. The following members of the Board considered AFBCMR Docket Number BC-2014-02977 in Executive Session on 14 Apr 15 under the provisions of AFI 36-2603: , Panel Chair , Member , Member All members voted to correct the records as recommended. The following documentary evidence was considered: Exhibit A. DD Form 149, dated 20 Jul 14, w/atchs. Exhibit B. Pertinent Excerpts from Personnel Records. Exhibit C. Letter, AFPC/DPFC, dated 9 Feb 15. Exhibit D. Letter, SAF/MRBR, dated 27 Feb 15. Exhibit E. Letter, Applicant, dated 14 Aug 13, w/atchs.