RECORD OF PROCEEDINGS
AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS
IN THE MATTER OF: DOCKET NUMBER: BC-2012-05571
COUNSEL: NONE
HEARING DESIRED: NO
APPLICANT REQUESTS THAT:
The X which someone put through a 26 Sep 66 entry in his medical records concerning a back injury, be removed.
APPLICANT CONTENDS:
Someone inappropriately placed an X through an entry in his medical records which showed treatment on 26 Sep 66 for a lower back injury he received while on active duty. He received the treatment, and remembers it well. He has been unjustly denied service connection for his back injury by the Department of Veterans Affairs (DVA) due to the X.
STATEMENT OF FACTS:
The applicant initially entered the Air Force on 18 Feb 65.
On 6 Dec 66, the applicant applied for a separation based on hardship in order to help support his father. The American National Red Cross confirmed the applicants father was in need of support, and his request was approved.
On 9 Jan 67, the applicant was furnished an honorable discharge certificate, and was credited with 1 year, 10 months, and 22 days of active service.
The remaining relevant facts pertaining to this application are contained in the memorandum prepared by the Air Force office of primary responsibility (OPR), which is attached at Exhibit C.
AIR FORCE EVALUATION:
The BCMR Medical Consultant recommends denial indicating there is no evidence of an error or an injustice. An episode of care reflected on one of the documents which the applicant submitted, clearly stamped 26 Sep 66, reads Patient has lower back strain following lifting heavy object. The pain this patient describes is localized on (L) side of back and doesnt radiate. Aggravated by motion. However, a large X is placed encompassing this entire medical entry, alongside are the hand-written words, WRONG CHART. A hospital summary in the applicants medical records, dictated on 14 Jan 77 (over ten years after his discharge) shows the applicant was hospitalized for back pain and bilateral popliteal pain. The hospital summary indicates the applicant reported previous episodes of back pain. The first episode reportedly occurred in 1968 (after his discharge). The applicant also received an orthopedic examination for rating purposes on 12 Dec 77 where he reported a history of having an onset of periodic low back pain with muscle spasms in 3-67. There is no history of any injury to his back. These symptoms occurred after he got out of the Air Force. A Report of Medical Examination for Disability Evaluation, completed 28 Mar 80, shows the applicant reported I started having back problems in March 67, but not bad enough to see a doctor until 1968. Another Compensation and Pension Exam Report, dated 4 Nov 93, shows In 1967 (this was after he was discharged), he strained his back lifting an air compressor out of the back of a pickup. A DVA rating decision, dated 29 Apr 13, showed his herniated disc and lumbosacral strain remained not service-connected. On the applicants separation physical, dated 20 Dec 66, the provider entered positive findings to include (1) pain in chest due to muscle spasms, (2) rash, and (3) depression. Prior to the advent of electronic medical records, procedures were established within medical treatment facilities for healthcare providers to follow when an erroneous medical records entry was made. This generally consisted of a straight-line made through the erroneous statement, along with the initials of the treating provider at either or both ends of the erroneous statement. Blackening or use of whiteout to cover the error was prohibited. In the case under review, a large X is placed over the entire back strain entry with the words WRONG CHART entered. This may have been an acceptable practice in 1966; but also noted there is no initialing by the provider. There is no way to validate whether or not the entry in question regarding back strain actually belongs to the applicant and, as he alleges, an X was maliciously placed in the record. However, the totality of evidence in its present state tends to suggest the entry was likely not intended for the applicant; particularly in the context of the divergent reported localization of the pain [Muscle Spasms in Chest] which matches the findings documented at his separation physical examination.
A complete copy of the BCMR Medical Consultant evaluation is at Exhibit C.
APPLICANT'S REVIEW OF AIR FORCE EVALUATION:
A copy of the Air Force evaluation was forwarded to the applicant on 27 Oct 14 for review and comment within 30 days (Exhibit D). As of this date, no response has been received by this office.
FINDINGS AND CONCLUSIONS OF THE BOARD:
After careful consideration of applicants request and the available evidence of record, we find the application untimely. Applicant did not file within three years after the alleged error or injustice was discovered as required by Title 10, United States Code, Section 1552 and Air Force Instruction 36-2603. Applicant has not shown a plausible reason for the delay in filing, and we are not persuaded that the record raises issues of error or injustice which require resolution on the merits. Thus, we cannot conclude it would be in the interest of justice to excuse the applicants failure to file in a timely manner.
THE BOARD DETERMINES THAT:
The application was not timely filed and it would not be in the interest of justice to waive the untimeliness. It is the decision of the Board, therefore, to reject the application as untimely.
The following members of the Board considered AFBCMR Docket Number BC-2012-05571 in Executive Session on 19 Feb 14 under the provisions of AFI 36-2603:
Panel Chair
Member
Member
The following documentary evidence was considered:
Exhibit H. Original Record of Proceedings.
Exhibit I. DD Form 149, dated 9 Jan 14, w/atchs.
Exhibit J. Memorandum, BCMR Medical Consultant, dated 6 Oct 14.
Exhibit K. Letter, SAF/MRBR, dated 27 Oct 14.
AF | BCMR | CY2004 | BC-2003-03911
A review of his medical records failed to show that his back injury was sustained on 12 Nov 65 as a result of a missile motor slipping its cradle during assembly in support of combat training missions. The Medical Consultant states a single medical record entry indicates he presented for lumbosacral back pain on 12 Nov 65 but no mechanism of injury is documented and there are no work-site accident or injury reports present in the records that may provide additional information. ...
AF | PDBR | CY2011 | PD2011-00839
The Physical Evaluation Board (PEB) adjudicated the LBP as unfitting, rated 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. The Board also considered the VA examination after separation ROM upon which the VA based its 20% rating.
AF | BCMR | CY2003 | BC-2003-01349
The applicant’s military medical records show medical entries for low back pain and/or strain as early as 1960, 1961, 1963, and 1965, without evidence of trauma. In a 24 Jul 80 letter to a veteran’s hospital, a civilian physical reports that the applicant had acute back strain in Jan 60, low back pain after lifting a heavy object in Mar 61, back pain in May 63, back pain due to lifting sand bags in Vietnam in Apr 67, intermittent back pain in Aug 67, and low back pain in Dec 67. A DVA...
AF | BCMR | CY2004 | BC-2003-03841
In support of his request, applicant provided a personal statement and documentation associated with his previous CRSC determination. There is no record of any particular injury received while handling munitions. _________________________________________________________________ THE BOARD DETERMINES THAT: The applicant be notified that the evidence presented did not demonstrate the existence of material error or injustice; that the application was denied without a personal appearance; and...
AF | PDBR | CY2013 | PD-2013-02197
It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.The rating for the unfitting thoracic musculoskeletal condition is addressed below.The requested bilateral knee condition, lumbar spine condition, left hand ulnar nerve dysfunction and hypertension (determined to be not unfitting by the PEB) are also addressed below.The...
AF | BCMR | CY2004 | BC-2003-03542
RECORD OF PROCEEDINGS AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS IN THE MATTER OF: DOCKET NUMBER: BC-2003-03542 INDEX CODE: 108.07 COUNSEL: NONE HEARING DESIRED: NO _________________________________________________________________ APPLICANT REQUESTS THAT: His service-connected medical condition, atherosclerotic coronary artery disease, be assessed as combat related in order to qualify for compensation under the Combat Related Special Compensation (CRSC) Act. ...
AF | BCMR | CY2004 | BC-2003-02532
His next entry for back pain was on 21 Mar 85 when he sought care for low back pain incurred while lifting a manhole cover. After a thorough review of the available evidence of record, it is our opinion that the service-connected medical conditions the applicant believes are combat-related were not incurred as the direct result of armed conflict, while engaged in hazardous service, in the performance of duty under conditions simulating war, or through an instrumentality of war, and...
AF | PDBR | CY2011 | PD2011-00884
The PEB adjudicated the chest pain due to costochondritis condition as unfitting, rated 20% with application of the Veterans Administration Schedule for Rating Disabilities (VASRD). Chest Pain Due to Costochondritis . The VA exam after separation indicated pain with motion and tenderness of the spine.
Based on the preponderance of evidence, and after a thorough review of the entire case file, the IPEB found that had these conditions been identified and presented to the board in the form of a special review prior to his discharge, they would have acknowledged their existence; however, they would not have considered them unfitting, ratable, or compensable under the provisions of military disability law and policy. A complete copy of the Air Force evaluation is attached at Exhibit...
AF | PDBR | CY2012 | PD2012-00570
Three months prior to separation, the PEB adjudicated the mechanical LBP post MVA condition as unfitting, rated 10%, with application of the DoD Instruction 1332.39 and Application of the Veterans Administration Schedule for Rating Disabilities (VASRD) under spine rules applicable on or before 23 September 2002. At the MEB exam, 5 months before separation, the CI reported pain‐“pains that radiate down the leg from back pains” on the DD 2807 without elaboration in the NARSUM. Service...