RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW
NAME: BRANCH OF SERVICE: army
CASE NUMBER: PD0900029 COMPONENT: active
BOARD DATE: 20090616 SEPARATION DATE: 20070102
________________________________________________________________
SUMMARY OF CASE: This covered individual (CI) was an active Army SGT 11B medically separated from the Army in 2007. The medical basis for the separation was traumatic back injury and Post Traumatic Stress Disorder (PTSD). The back injury was from a Bradley rollover while in combat in Iraq in Jul 2004 and PTSD was from other combat situations in Iraq in 2004. CI was referred to the PEB, found unfit and separated at 20% disability. The PEB 10% back rating was similar to the VA back rating and was not contended. The PEB rated PTSD at 10% and specified that CI was only partially compliant with medical treatment for PTSD. The VA rated PTSD originally at 50% IAW §4.129 Mental disorders due to traumatic stress. On re-exam of 20070524 the PTSD rating was initially changed to 30%, but on reconsideration and re-exam of 20071023 was upgraded retroactively to 70%. The CI contends that ‘Rating for severe PTSD was much too low’, CI mentions NDAA, VASRD and his PTSD symptoms.
________________________________________________________________
BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The PEB’s deduction due to CI’s ‘partial compliance’ may certainly be attributed to his primary PTSD versus personality traits, is mitigated as the CI accepted individual counseling at the session for his NARSUM psychiatry addendum (13 Sep 2006), the mixed prognosis provided in that addendum, as well as CI’s increased symptoms following service discharge. The NARSUM also stated ‘COMPLIANCE STATEMENT: There is no indication of noncompliance with medical treatment or recommendations.’ Therefore, the Board did not support decreasing any PTSD rating for noncompliance, even if the MEB exam were used for rating versus an extrapolation to CI’s condition post-discharge IAW §4.129 Mental disorders due to traumatic stress. If the MEB exam were rated IAW the DoDI, without deduction, it would rate between the 30% and 50% levels. The VA exam of 20070524, coupled with VA treatment notes, clearly rate at the 50% level which is the closest approximation to CI’s condition if reevaluated within 6 months following discharge. The 20071027 VA exam clearly showed CI at the 70% rating; however, the Board opined this as worsening of CI’s PTSD beyond the 6 month post discharge timeframe of §4.129. The Board did not agree with the VA rationale of a 70% rating at the first VA PTSD re-evaluation point based on granting retrospective suicidal ideation at the time of the prior exam, despite CI’s negative replies to suicidal ideation.
________________________________________________________________
RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation.
| Unfitting Condition | VASRD Code | Rating |
|---|---|---|
| Traumatic back injury | 5237 | 10% |
| PTSD | 9411 | 50% |
| Combined | 60% |
________________________________________________________________
The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20090115, w/atchs.
Exhibit B. Service Treatment Record.
Exhibit C. Department of Veteran's Affairs Treatment Record.
AF | PDBR | CY2010 | PD2010-01025
The CI was treated with medications and outpatient therapy, but failed to improve adequately to meet the operational requirements of his Military Occupational Specialty (MOS). The PEB of 31 May 2005 found the CI unfit for PTSD, VA Code 9411, but stated that the CI was “non-compliant with refusal to discontinue excessive alcohol and narcotic usage.” The PEB removed him from TDRL and assigned a 10% final disability rating stating, “rating apportioned downward for non-compliance.” The CI...
AF | PDBR | CY2009 | PD2009-00134
The CI was medically separated with a combined disability rating of 20%. Disc Disease L4/5…524120%20080717LLE Radicular Pain > Combined with back rating.20070531Radiculopathy, LLE5241-852010%20080717↓No Additional DA 3947 Entries.↓Degen. The Board, therefore, recommends that it be rated as an additionally unfitting condition.
AF | PDBR | CY2009 | PD2009-00177
The CI was medically separated by the PEB at 10% disability for depression with elements of PTSD. The case should have been adjudicated IAW VASRD §4.129 and the Board must therefore recommend a 50% TDRL rating at separation, coded 9434-9411. TBI was alluded to in the VA psychiatric rating examination, but the condition has yet to be coded and rated by the VA.
AF | PDBR | CY2009 | PD2009-00145
Discussion: The CI was diagnosed with PTSD and was found unfit for PTSD at 10%. VARD (diagnosed as Tinnitus) 20080516 and rated it at 10% based on exam of 20080107: The condition is noted in your service treatment records as of May 3, 2007; We have assigned a 10 percent evaluation based on examination findings that has determined, your tinnitus is persistent in nature; the diagnosis that has been given is ringing in the left ear. There is no hearing loss present on the right and there is...
AF | PDBR | CY2012 | PD2012 01496
Although she continued to endorse symptoms of PTSD, her GAF was 60 which correlated with moderate symptoms or moderate difficulty in social, occupational, or school functioning.The documents did not cite evidence which would confirm that either reliability or productivity on the job was suffering because of psychiatric symptoms, and both speculation and liberal reliance on reasonable doubt would be required to draw that conclusion.Her level of disability at that time was most consistent with...
AF | PDBR | CY2010 | PD2010-01022
Since this was not the case, the Board will rate the total psychiatric impairment as if the two conditions were a single unfitting condition under code 9411 for PTSD with MDD. After this examination his VA disability rating was increased to 100% for an exacerbation of his condition and was not considered permanent. At the time of his separation from the TDRL in 2008 his VA disability rating was 70%.
AF | PDBR | CY2012 | PD2012 01572
The examiner further opined that the CI had severe military and civilian impairment and that without therapy or medication, the probability for his continued mental deterioration was “extremely high” and that even with ongoing treatment theprognosis was “still guarded.” He also stated the CI’s mental illness was severe, chronic, and unfitting and he highly recommended the CI initiate psychotherapy and medication at the VA.The C&P examination approximately 4 monthsafter permanent separation...
AF | PDBR | CY2011 | PD2011-00039
The Board must then determine the most appropriate fit with VASRD 4.130 criteria at six months for its permanent rating recommendation. Personality disorder and non-cardiac chest pain were discussed in detail under anxiety disorder above. As discussed above, PEB likely reliance on DoDI 1332.39 for rating the anxiety disorder condition was operant in this case and the condition was adjudicated independently of that instruction by the Board.
AF | PDBR | CY2012 | PD2012-00021
Furthermore, IAW DoDI 6040.44 and DoD guidance (which applies VASRD §4.129 to all Board cases), the Board is obligated to consider if the definition of §4.129 is met for any psychiatric condition resulting in medical separation; i.e., “a mental disorder that develops in service as a result of a highly stressful event.” The evidence is clear in this case that all of the elements for application of §4.129 were met. At the VA Compensation and Pension (C&P) exam, performed 2 weeks prior to...
AF | PDBR | CY2011 | PD2011-01043
The Board first considered the rating at the time of separation. The requirement for antipsychotic medication, the occupational impairment described by the commander and the need for hospitalization were considered to be indicators of the serious nature of the mental condition, and weighed heavily 3 PD1101043 in the Board’s deliberation. In the matter of the bipolar disorder PTSD condition, the Board by a vote of 2:1 recommends an initial 4 PD1101043 UNFITTING CONDITION Bipolar Disorder...