RECORD OF PROCEEDINGS
IN THE CASE OF:
BOARD DATE: 19 APRIL 2005
DOCKET NUMBER: AR20040003121
I certify that hereinafter is recorded the true and complete record
of the proceedings of the Army Board for Correction of Military Records in
the case of the above-named individual.
| |Mr. Carl W. S. Chun | |Director |
| |Mr. Kenneth H. Aucock | |Analyst |
The following members, a quorum, were present:
| |Mr. Raymond Wagner | |Chairperson |
| |Mr. Larry Bergquist | |Member |
| |Mr. Larry Olson | |Member |
The Board considered the following evidence:
Exhibit A - Application for correction of military records.
Exhibit B - Military Personnel Records (including advisory opinion,
if any).
THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE:
1. The applicant requests physical disability retirement or separation;
that he be reimbursed for all his medical bills and his expenses that were
related to his injuries on 25 March 2001; that he receive incapacitation
(incap) pay and/or active duty medical extension (ADME) pay from 25 March
2001 to the present, less the six months that he did receive ADME pay, from
21 August 2002 to 17 January 2003. He also requests that his NGB
Form 22 (Report of Separation and Record of Service) be changed to show -
his date of enlistment as 19 April 1995, his date of rank as 22 July 1997,
his record of service be corrected accordingly, his completion of basic
training be reflected on that form, and his name be corrected, e.g., his
first name and middle name are reversed. He also requests that the line of
duty investigation be corrected to show all the injuries that he received
on 25 March 2001.
2. The applicant states that the Maryland Army National Guard (MDARNG)
made numerous errors concerning his discharge and the handling of his
injuries that were caused during inactive-duty training, which has left him
permanently disabled.
a. He was on active-duty for training on 25 March 2001 when his body
was crushed between two Humvees (military vehicles) at approximately 1500
hours at the Pikesville Military Reservation in Baltimore, Maryland. Then
on 16 March 2002 he was ordered to report to Pikesville Military
Reservation by Captain “G,” against doctors’ orders and was injured further
when he was hit on the back.
b. He was treated by civilian doctors from the date of the accident
to the present time. He was seen only three times by military doctors – 6
November 2001, 16 March 2002, and 21 August 2002. On 21 August 2002 he was
placed on ADME to enable the Walter Reed Army Medical Center (WRAMC) to
evaluate his injuries; but was never notified of any further appointments.
He stayed in contact with Sergeant “R” (National Guard liaison at WRAMC)
from 21 August 2002 until 17 January 2003, when he was taken off ADME,
without ever having been seen by a doctor. All his pay was stopped.
c. He elected to be treated by civilian doctors and received
permission from Captain “G” (Battalion adjutant and LOD (line of duty)
investigating officer) and Sergeant “R,” with the understanding that the
military would assume his treatment, which never happened.
d. He sustained several primary injuries on 25 March 2001. He lists
those as mild traumatic brain injury, neck and back injuries, right arm and
elbow injury, left rib injury, bowel and bladder problems, and
psychological disorders. Under each of those, he lists associated
secondary injuries, which are depicted in his request.
3. The applicant provides a copy of a 21 May 2004 to the Department of
Veterans Affairs (VA) from the applicant’s wife commenting on his injuries
and disabilities. He provides over 600 pages of documents in 50 tabs for
which he includes a table of contents with his application, and which are
appropriately depicted herein.
4. The available evidence in this case is that submitted by the applicant.
COUNSEL'S REQUEST, STATEMENT AND EVIDENCE:
Counsel was notified that the applicant’s case was available for review,
but failed to respond.
CONSIDERATION OF EVIDENCE:
1. The applicant enlisted in the Wyoming Army National Guard on 20 April
1995. He was promoted to pay grade E-4 on 22 July 1997, and promoted to
candidate E-6 on 9 January 1998. On 27 March 1998 he was transferred to a
National Guard unit in Houston, Texas. On 17 November 1998 he was
transferred to the 2nd Battalion, 110th Field Artillery, a National Guard
unit in Pikesville, Maryland. He was reduced to his former pay grade of E-
4, with a date of rank of 1 December 1998, because of his
resignation from officer candidate school.
2. On 25 March 2001, while on inactive duty for training at the Pikesville
Military Reservation, he received injuries to his right arm and left lower
rib area when he was pinned between two vehicles. The Statement of Medical
Examination and Duty Status, DA Form 2173 (line of duty investigation)
showed that a battalion medic performed an initial evaluation, indicating
that the applicant appeared to have fractured bones. The applicant was
taken by ambulance to the Sinai Medical Center in Baltimore. Statements
were taken from six Soldiers who either observed the accident or arrived
shortly thereafter. Two indicated that the applicant complained of
injuries to his right arm and left lower rib area (or left mid area). The
others stated in effect, that the applicant was holding his right elbow and
left side. The applicant’s commanding officer, Captain “Z” stated that his
injury was in line of duty.
3. On 28 March 2001 the applicant completed a disability counseling
statement stating that he understood that to be eligible for continuance of
pay and allowances while disabled he had to notify his unit when in need of
any medical or hospital care required as the result of his line of duty
injury, that he could not seek medical or hospital care without first
requesting and receiving approval from his unit, that he had to report for
any medical appointment scheduled by his unit or by the treating physician
in regard to his LOD incident, that he had to cooperate fully with the
medical personnel providing treatment and follow their course of treatment,
and that he had to furnish his unit within 3 working days of completion of
each of his medical appointments, documentation on the results of those
appointments. He agreed to certain other conditions, to include submitting
copies of pay stubs, claim forms, and statements of income. He agreed to
report any monies received from an insurance company. He stated that he
understood that he was not on active duty while incapacitated. He stated
that he understood that failure to fulfill the requirements contained in
the statement could result in termination of his entitlement to pay and
allowances and medical care for his disability.
4. The LOD investigating officer, Captain “G,” indicated on 28 March 2001
that the applicant elected not to make a statement. On 19 April 2001 the
State of Maryland Military Department determined that his injury (right
elbow contusion) was in line of duty.
5. On 22 May 2001 the applicant completed a Form 46-1-R (a form which is
submitted with initial incapacitation pay monthly claim form), witnessed by
the battalion adjutant, Captain “G,” in which he stated that he understood
and agreed to certain conditions, to include receiving written
authorization from a military medical facility before obtaining medical
treatment from any civilian source or to be personally responsible for any
charges incurred; and submitting to all military medical treatment
including reporting for medical fitness examinations with the understanding
that failure to do so could result in termination of incapacitation pay.
6. The applicant extended his enlistment on two occasions, for six months
on 19 April 2001, and again for six months 18 October 2001, making his
ETS (expiration of term of service), as indicated on his oath of extension
as 19 April 2002. Noted however, is the fact that the applicant enlisted
in the Army Reserve for 8 years on 20 April 1995, which would appear to
make his ETS as 19 April 2003, making the extensions superfluous.
7. On 26 October 2001 orders were published by the State of Maryland
Military Department attaching the applicant to WRAMC with a reporting date
of 6 November 2001. The purpose stated was “INCAP –
Disease, Non-contingency.” On 6 November he was examined by a Doctor “C,”
an orthopedist at WRAMC, for his right elbow contusion.
8. On 16 March 2002 a Maryland Army National Guard doctor, Lieutenant
Colonel (LTC) “Y” gave the applicant a temporary profile until 16 September
2002, indicating that the applicant should not have physical training or
testing, and that he was unable to attend unit drills. He stated that the
applicant had been to WRAMC once on 6 November 2001 and was awaiting
paperwork in order to continue his evaluation, and that in the meantime he
was being followed by a civilian doctor. He stated that the temporary
profile was accomplished in order to allow more time for treatment and
disposition.
9. On 21 August 2002 the applicant requested extension on active duty to
receive medical treatment for the injuries that he received while on active
duty. He stated that he understood that he would be assigned to the
closest medical treatment facility to his home and might be provided an
opportunity to perform duty at a unit near his home. In a note on that
request a statement was made that the applicant would continue medical
treatment with a civilian provider until disposition by a medical treatment
facility (MTF). He agreed to report for duty on the date and time
specified on his orders. He agreed to keep his chain of command informed
of all medical appointments and agreed to attend all medical appointments.
In a note on his request a statement was made that the applicant’s wife
would call and/or e-mail SFC “F” or SSG “R” (National Guard Bureau/Reserve
Components LNO (Liaison Officer)).
10. A doctor at WRAMC, LTC “X,” completed a Form 46-2-R, Military
Physician’s Statement, Soldier’s Incapacitation/Fitness for Duty, in which
he stated that he examined the applicant on 21 August 2002 and that he was
not fit to perform his military duties or his civilian job from 21 August
2002 until 31 January 2003. He also stated that a review of the
applicant’s medical documentation indicated PTSD (posttraumatic stress
disorder) secondary to a HUMVEE accident, where his original injury was to
his right arm and lower rib area. He stated that the applicant needed to
be seen and evaluated by a neurologist/psychologist for medical issues not
diagnosed by a medical treatment facility for follow up care, and a
possible Medical Evaluation Board (MEB)/Physical Evaluation Board (PEB).
11. On 28 August 2002 the Army Personnel Command in St. Louis published
orders ordering the applicant to active duty (ADME) with a reporting date
to WRAMC on 21 August 2002 for 150 days, the ending date to be 17 January
2003. He was ordered to ADME to perform special work in his current
Reserve grade.
12. The applicant was discharged from the Army National Guard and as a
Reserve of the Army on 19 April 2003 on his ETS. His character of service
was honorable. His date of enlistment is shown as 27 May 1998, and his
date of rank as 1 December 1998. He had 4 years, 10 months, and 24 days of
service, and 4 years of prior Reserve component service. His first name
and middle name on his separation document are reversed.
13. The applicant provided a 13-page chronology of the events concerning
his injuries from the time of the accident until February 2003.
14. The applicant submits copies of 53 e-mails regarding his situation,
from 26 March 2001 to 30 March 2002. Most of that correspondence was
with unit personnel, updating them on his condition, trying to resolve his
problems in having his medical bills paid, and in obtaining appointments
for his medical condition.
a. On 26 March 2001 his wife informed his unit that the applicant’s
ribs and back were really sore, and his whole upper body was suffering, but
his elbow was worst of all.
b. On 13 May 2001 he indicated problems with his medical bills.
c. On 13 and 14 May 2001 he informed his commanding officer,
Captain ”Z,” that Captain “G,” [the battalion adjutant and the LOD
investigating officer] informed him on 10 April 2001 that he could no
longer see his civilian doctor. He stated that he had not yet seen a
military doctor, but was continuing to see civilian doctors, and paying
them with his insurance and his own money. He stated that Captain “G”
informed him that Sergeant “B” would schedule an appointment for him. He
stated that Sergeant “B” informed him, in the meantime to continue being
treated by his civilian doctors and to send the bills to the National Guard
and hope that they would pay. He stated that Captain “G” also told him
that he would have to extend for 6 months in order to continue to receive
medical treatment from the National Guard.
d. In response to an e-mail from his commanding officer, he stated
that he had not yet seen a military doctor, but was getting care from his
primary physician, paying the bills through his insurance and out of his
own pocket. He stated that as of 10 May 2001 he had been cleared to return
to work full duty by his primary physician. He stated that he wanted to
inform everyone of his situation in hopes that it would be resolved soon.
e. On 17 June 2001 he stated that he was receiving medical bills and
had not yet been seen by a military doctor. He stated that he contacted
the IG (Inspector General) for assistance.
f. On 25 July 2001 a unit member, Major “VO” indicated that the
5th Regiment, MDARNG, had filed claims with TRICARE, and that two
[of his] doctors needed to send forms to TRICARE. He stated that billing
system sends bills to the applicant also [the same bills]. He stated that
the 5th was trying to find out why it took so longer for the applicant to
see a military doctor, in order to process [him] for incapacitation pay.
g. On 27 July 2001 Sergeant First Class (SFC) “T,” a member of his
unit, informed the applicant to contact Mrs. “W” at STARC (State Area
Command) regarding an appointment with a specialist. On that same date,
Major “VO” informed SFC “T” to advise the applicant not to pay bills and if
he received any to contact him for assistance.
h. On 30 July 2001 the applicant’s commanding officer advised him to
extend his enlistment in order to get his bills paid prior to leaving the
National Guard. On that same date the applicant advised his commanding
officer of the bill he received from Sinai Hospital and questioned why it
was not paid [by the National Guard].
i. On 18 October 2001 Captain “G” notified the applicant that he was
scheduled for an appointment with Doctor “C,” an orthopedic specialist, at
WRAMC on 6 November 2001. He was also notified to come to the unit to sign
a six-month extension of his enlistment.
j. On 5 February 2002 the applicant notified Sergeant “T” that he
retained an attorney, and made mention of the emergency brake malfunction
on the HUMVEE.
k. On 12 March 2002 the applicant notified Sergeant “T” that he was
informed that he had to attend drill [the unit was notified that it might
be mobilized]. He stated that because of his current condition he was
unable to travel long distances by vehicle. He stated that his attorney
had advised him not to speak with Captain “G.” Captain “G” informed
Sergeant “T” that he would not speak with the applicant’s attorney.
l. On 13 March 2002 Major “VO” indicated to Sergeant “T” that he was
waiting for the applicant to show up with his medical paperwork. He
questioned why the applicant’s attorney needed to get involved in this
matter.
m. On 30 March 2002 the applicant informed Sergeant “T” that he was
undergoing therapy for his back and neck.
15. The Military Medical Support Office in Great Lakes, Illinois, in
processing the applicant’s request for TRICARE benefits, indicated on 4
June 2001 that the applicant’s request for payment of medical services
(nausea with vomiting) provided by Doctor “B” on 4 April 2001 was not
allowed because the diagnosis on his DD Form 2173 (LOD investigation) did
not match [the services provided]. On 25 June 2001 the applicant appealed
to the Military Medical Support Office, stating that he started having
additional symptoms after his accident – neck and back pains, extreme
tiredness, trouble seeing, dizziness, blacking out, upset stomach, nausea,
soft stool, and continued dehydration. He called his primary physicians,
Doctor “B” and Doctor “D,” who told him to come in immediately on 4
April 2001.
16. TRICARE statements show the medical services provided to the
applicant, e.g., orthopedic, radiological, neurological, and outpatient
visits, from March through May 2001 and in September 2001, and the amount
allowed by TRICARE. In some instances, payment for some radiological
services and neurological services were denied.
17. On 7 August 2001 the United States Capitol Police, the applicant’s
employer, submitted a list of the hours of sick leave used by the
applicant. The list shows that he was on sick leave or scheduled time off
from 26 March 2001 to 10 April 2001 and that he returned to duty on 11
April 2001.
18. On 8 August 2001 the applicant submitted Incapacitation Pay Monthly
Claim Forms (Forms 46-R), verified by his employer, stating that he was not
able to work from 25-31 March 2001, 1-10 April 2001, 23 April 2001, 26
April 2001, 30 April 2001, and 10 May 2001. Those forms do not show
his commander’s verification or approval of his claims.
19. Leave and earning statements show the applicant’s work hours, annual
leave, sick leave, and regular military leave taken from 25 February 2001
to 2 June 2001, in addition to his earnings and deductions. The
statements show that for the pay period 8 April – 21 April 2001 he worked
56 hours, had 16 hours annual leave, and 8 hours compensatory time; for the
pay period 22 April – 5 May 2001, he worked 56 hours
and had 24 hours compensatory time; for 6 May – 19 May 2001, he worked 64
hours, and had 16 hours compensatory time; and for 20 May – 2 June 2001, he
worked 64 hours, had 8 hours compensatory time and 8 hours of other
leave time.
20. Military leave and earning statements reflect his entitlements and
deductions from February 2001 to December 2001. He received no pay from
April to December 2001, for May 2002, or for August 2002. He received pay
for IDT (inactive duty for training) on 16 March 2002, and received active
duty for training (ADT) [while in was in an ADME status] pay from 21 August
2002 to 17 January 2003.
21. Medical reports show:
a. A radiological report prepared at the Sinai Hospital of Baltimore
shows that the applicant was examined on 25 March 2001, the date of his
accident. Chest examination showed minimal right hemidiaphragm elevation.
No lung infiltrates were noted in the chest. There were no fractures noted
in the right hand and wrist, the right humerus, or the right radius and
ulna.
b. On 27 March 2001 the applicant was examined by an orthopedist. He
stated that the applicant’s right shoulder and right wrist were tender. He
indicated that x-rays of his right elbow showed no fracture. He diagnosed
the applicant as having a right elbow contusion, and stated that he could
do light duty, but no heavy use of the right upper extremity for two weeks.
c. On 3 April 2001 the applicant had an MRI (magnetic resonance
imaging) of his right elbow. The impression shown was a diffuse muscle
edema in the medial and lateral aspect of the triceps without tear of the
actual triceps tendon. There was a ganglion cyst which represented an
incidental finding.
d. A 4 April 2001 CT (computerized tomography) scan of his brain was
normal. A 4 April 2001 radiology report showed that his cervical spine
was normal.
e. An 18 April 2001 radiology report of his chest indicated no acute
cardiopulmonary process; of his abdomen, no abdominal abnormalities
identified; of his thoracic spine, no evidence of acute fracture or
dislocation. On 18 April 2001 the applicant had a CT scan of the abdomen
and the pelvis. The findings were normal. On 26 April 2001 the applicant
had an upper GI and small bowel series. The findings were normal.
f. On 30 April 2001 a neurologist informed the applicant’s physician
that he had examined the applicant. He stated that the applicant presented
vague symptoms of anorexia, nausea, dizziness, without clear vertigo or
positional symptoms, that he had an uncertain head injury and that there
was no clear loss of consciousness associated with this. He stated that
because of the dizziness and anorexia, he would look into autonomic
problems as the cause and would get an EEG (electroencephalogram) to look
for subtle brain injury.
g. The applicant had a myocardial perfusion scan on 1 October 2001.
He had a normal myocardial perfusion study and a normal ejection fraction.
h. A 5 October 2001 evaluation by a doctor of rheumatology for his
complaints of joint pain, fatigue, and rash. His diagnoses of the
applicant’s condition included low positive ANA (antinuclear antibodies)
with occasional sores in the mouth, traumatic brain injury with history of
concussion followed by multiple problems of polyarthralgias, insomnia,
severe fatigue, and occasional blurred vision. In a follow-up letter to
his physician, the doctor stated that he suspected that his multiple
problems of insomnia, severe fatigue, polyarthralgias, and occasional
blurred vision were most likely due to his traumatic brain injury which
occurred on 26 March 2001 at his job.
i. In a 26 October 2001 letter to the WRAMC, the applicant’s civilian
physician, Doctor “D,” stated that the applicant had no recollection of the
accident. She stated that since the accident the applicant had experienced
worsening fatigue, dyspnea on exertion, headaches, visual changes,
abdominal pain, chest pain, and diffuse musculoskeletal weakness. She
stated that he had been evaluated by cardiology, neurology, general and
orthopedic surgery, and ophthalmology; that he had abdominal and chest CT
scans, x-rays, EEG, EKG (electrocardiogram), stress thallium and ECHO,
upper GI, MRI and x-ray of his elbow, as well as many lab tests. She
stated that all his symptoms began after the accident; however, there was
still no clear diagnosis.
j. A 10 December 2001 MRI of his cervical spine indicated an
essentially normal imaging. An MRI of the brain indicated a polyp, right
maxillary sinus; otherwise an essentially normal imaging. An MRA of the
brain indicated an essentially normal MRA.
k. A 27 December 2001 radiology report shows that his chest was
normal. A report shows that he had a normal lung scan.
l. A 21 January 2002 radiology report of his chest indicated no
active lung disease.
m. A 31 January 2002 evaluation by a doctor at the Brain Injury
Clinic at Kernan Hospital in Baltimore - That doctor stated that the
applicant had had numerous work ups and had been seen by a cardiologist, a
neurologist, an orthopaedic surgeon, a rheumatologist, and an
ophthalmologist. He has had various evaluations and clinical
investigations, to include CTs, MRI of the brain, and MRA of the brain as
well as a stress thallium test and echocardiography. All of the tests were
inconclusive. The doctor’s impression – normal neurological exam; multiple
somatic complaints, some of which were consistent with a constellation of
post-concussive injury although there was no clear documented or reported
head injury evident in his history; mixed type cephalgia [headache];
anxiety disorder with increasing problems with agoraphobia [intense,
irrational fear of open spaces] and worsening problems with irritable bowel
syndrome; and irritable bowel syndrome. He stated that he discussed the
treatment options with the applicant and also told him that he had no clear
diagnosis for his multitude of symptoms.
n. A 12 February 2002 radiology report of his throracic spine was
normal. The report of his lumbosacral spine and pelvis showed that L5 was
asymmetric with the right transverse process being incompletely sacralized.
There was no evidence of facture.
o. A 25 March 2002 dynamic motion x-ray study indicated normal motion
at the atlanto-occipital articulation, disruption of the posterior
longitudinal ligament between C2 and C3; and disruption of the posterior
longitudinal ligament between C3 and C4. The doctor conducting the study
stated that there was objective evidence of permanent impairment and that
alteration of motion segment integrity with at least 3.5mm translation of
one vertebra on another during flexion and extensions had a ratable whole
person permanent impairment of 25-28 percent, and that forceful adjustments
to those areas should be avoided.
p. An 11 April 2002 evaluation by a neurologist - His assessment –
The applicant had multiple problems which were neurological sequela of the
accident. He showed signs and symptoms of postconcussional syndrome. His
headache postconcussional, aggravated by his posttraumatic stress disorder,
anxiety and depression, and craniocervical myofascial dysfunction were
intense and operative. He had syncopal [fainting] episodes. He had vision
fusion difficulties, which needed to be addressed by a neuro-
ophthalmologist. He had paresthesias [abnormal sensations, such as
burning, prickling] in both hands and radicular pain from the neck to the
head and shoulder blades from cervical radiculopathy.
(1) The applicant was followed up on 9 May 2002. The neurologist
indicated that his headache was less, and that his vision was evaluated by
a neuro-ophthalmologist, who opined that the applicant had posttraumatic
mild divergence insufficiency as a result of difficulty of fusion task. He
had follow-ups on 23 May 2002 and on 6 June 2002. In an 11 July 2002
follow-up the doctor stated that the applicant’s daily headache had abated
completely, but that the applicant stated that his dizziness was
persistent. The doctor stated that the applicant’s vertigo was persistent,
and the clear discharge from his nose and ears persisted. He opined that
the applicant was having perilympahtic fistula.
(2) He had a follow-up on 20 February 2003. The doctor indicated
that the applicant had been seen by an ophthalmologist who recommended that
he undergo eye therapy. He was seen by an otolaryngologist who told him
that his ear was normal. The applicant stated that he had panic attacks.
(3) He was evaluated on 9 December 2003. The assessment –
posttraumatic CSF fistula cleared spontaneously; posttraumatic vertigo rule
out perilymphatic fistula; PTSD; cervical and lumbar strain; cervical
radiculopathy; and posttraumatic seizures to be determined.
(4) He was evaluated on 13 February 2004. Evaluations by a doctor
for his vertigo and dysequilibrium indicated that he had perilymphatic
fistula bilaterally. He had chest pain associated with walking on a slight
incline. He had bladder and bowel loss of control. He had sexual
difficulty, constant neck pain and numbness of both hands.
q. The applicant was examined by a psychologist on 29 April 2002.
His condition was diagnosed as PTSD, major depression single episode, pain
disorder associated with psychological factors and a general medical
condition, secondary insomnia, headaches, TMS, and gastrointestinal
complications, and severe psycho-social stressors. He was examined again
in August 2002, at which time the psychologist stated that the applicant
continued to struggle with pain and depression, but that his insomnia had
improved. He had to constantly urinate and his urologist told him that was
because of nerve damage in that area. He had radical mood changes and anger
outbursts, due to his agitation and frustration. The psychologist stated
that with reasonable psychological certainty, his symptoms were the direct
result of his trauma on 25 March 2001. He had another follow-up in
September 2002 at which time the psychologist stated that he agreed with
the recommendation made as a result of a neuropsychological examination
that the applicant undergo psychotherapy and physical therapy to regain his
homeostasis.
r. On 1 May 2002 the applicant was seen by a neuro-ophthalmologist
for consultation regarding diplopia [the perception of two images of a
single object]. The impression – mild esophoria but with no evidence of
any limitation of eye movements, no abnormalities of pursuit or saccades,
and no evidence of any nystagmus. The examining doctor reassured the
applicant as to the healthy nature of his eyes, and indicated that it was
not uncommon following head injuries to have problems with fusion tasks,
and for that reason he was developing mild divergence insufficiency. The
applicant returned for a follow-up visit on 5 September 2002. The
examining physician stated that measurements were consistent with a
divergence insufficiency, and the majority of the cases were self-limited;
however, the applicant continued to have the problem.
s. On 10 July 2002 and 1 August 2002 he underwent a
neuropsychological evaluation. The psychologist administered numerous
tests. In summary, she stated that the applicant had sustained two
accidents in the past year and a half, and since then reported a wide range
of physical and cognitive difficulties. He had not worked since the second
accident in March 2002. Medical workup to date had been negative. She
stated that testing found slower than expected motor speed, particularly
with the dominant hand. He also evidenced mild impairment in naming as
well as slightly reduced general conceptualization abilities; however, he
generated an invalid profile on a measure of response style, calling into
question the validity of those findings. He showed only minor impairment
in a few areas of neuropsychological testing which did not correspond with
the complaints he mentioned and which did not appear to comprise his
functioning to a notable extent. The main finding was reduced motor speed,
particularly on the right side. There was no indication of head injury or
of notable cognitive impairment. She stated that personality testing
indicated that the applicant was responding to stress by developing
physical symptoms, and that many of the symptoms he reported were
indicative of a conversion disorder. There appeared to be no organic basis
for the myriad of complaint that he puts forth. He did have a mild post
traumatic reaction to the incidents which occurred at the National Guard,
which was not surprising. She stated that the first accident engendered
tremendous vulnerability which the applicant had converted to more
socially, and personally, acceptable physical symptoms.
t. In a 10 January 2003 report by that same psychologist, she stated
that the applicant and his wife sought a follow-up appointment, and brought
various medical reports with them. They attempted to show that some of the
reports were consistent with a head injury; however, the psychologist
stated that none included cognitive testing. She clarified that there
could be bona fide physical findings in addition to the presence of a
conversion disorder. She urged the applicant to pursue treatments which
had been beneficial to him, and recommended the possible benefit of
psychological treatment. She stated that based on cognitive testing, there
was no evidence of head injury.
u. In a 25 July 2002 report a chiropractor stated that the applicant
had been under his care since January 2002. He stated that motion x-rays
showed that the applicant was found to have a disruption of the posterior
longitudinal ligament between C2 and C3 and between C3 and C4, which
allowed for permanent laxity and permanent aberrant joint motion in the
movement of the bones of his neck. He stated that it was a permanent
condition that could not be fixed and was likely to get worse with time.
He stated that the applicant was asked to list activities of daily living
that were affected by his condition. He listed over 200 activities, to
include archery, dart, Frisbee throwing, walking, photography, eating out,
going to movies, reading, visiting friends, lifting, setting table, opening
cans, dusting, ironing, mopping, changing light bulbs, feeding dog,
caressing, feeling attractive, touching, brushing teeth, chewing, flossing,
zippering, holding a mug, getting up, standing, whistling, anger,
irritability, memory loss, etc.
v. In a 25 July 2002 letter, his civilian physician provided an
update to WRAMC of what she indicated was his deteriorating condition. She
stated that he was forced against medical advice to return to the National
Guard on 16 March 2002 where he suffered a whiplash injury,
which made all of his symptoms worse. In another letter of that same date,
she stated that the applicant suffered from continual neck and back pain,
blurred vision, dizziness and fatigue, all of which were exacerbated by any
physical activity. He could not sit or stand for more than one hour at a
time. He has been followed by neurology, physical therapy,
neurophathalmology and herself, and forced to take medication daily which
dulled the pain, but caused nausea and drowsiness. She stated that in the
two years since the crush injury, he has made no physical progress and she
doubted that he ever would.
w. On 5 August 2002 the applicant was sent for an orthopaedic
evaluation, complaining of constant headaches and dizziness. The
orthopedist stated that the applicant indicated he as having diffuse pain,
was taking medications, and was doing some acupuncture. She indicated soft
tissue injury; however, there were no films available for her review. He
followed up on 10 September 2002, at which time the orthopedist
stated that she felt that all that he had was soft tissue damage and she
had nothing else to offer him. He had a follow-up on 27 September 2002.
The applicant stated that he was getting more tightness in his cervical
area and noted that his vertigo and headaches were returning. The
orthopedist indicated that the cervical range of motion was slightly
restricted in rotation with some banding in the cervical paraspinals. She
stated that she did not think more physical therapy would help him and that
he would most likely have to manage on his own on a long term basis. He
followed up on 29 October 2002. The applicant stated that physical therapy
had helped, and that he only needed maintenance therapy. The orthopedist
stated that his cervical range of motion was full and that motor and
sensory examinations, as well as reflexes were intact. She stated that he
did not need any more physical therapy.
x. On 14 November 2002 and 29 November 2002 the applicant had an MRI
of the thoracic spine. There was mild dextroscoliosis. There was no
fracture. The pedicles were intact and there was no paraspinal
abnormality. There was no acute bony abnormality of the thoracic spine.
No intrinsic abnormalities were noted. An MRI of the cervical spine
indicated no significant radiologic abnormality.
y. On 26 November 2002 the applicant underwent an evaluation at the
Washington Adventist Hospital, Department of Rehabilitation Medicine. The
examining physician indicated that the applicant stated that on 10 November
2002 he was in a Bowie movie theater when someone approached him from
behind, and stated that he was sitting in their seat. They struck him in
the head, neck, and shoulder area, and pushed him forward. Subsequent to
that time he had been experiencing pain and was therefore referred to this
office. He underwent x-rays, which showed only mild dextroscoliosis of the
thoracic spine and normal cervical spine alignment. The doctor recounted
his past medical history, indicated the multiple symptoms that the
applicant described, and diagnosed his condition as cervical and thoracic
pain following trauma on 10 November 2002; muscle spasms and
trigger points and somatic dysfunction with associated myofascial pain,
possible underlying cervical radiculopathy. He had a follow-up on 19
December 2002. The physician indicated that he had a new complaint of pain
in the low back area. He underwent an EMG (electromyogram) study on 27
November 2002, which showed mild cervical radiculitis, C8. The doctor
diagnosed his condition as cervical radiculitis following the assault of 10
November 2002.
z. He was examined by a doctor on 4 February 2003, who diagnosed his
eye condition as binocular dysfunction (accommodative inadequacy), and
indicated that the applicant was in vision therapy.
aa. In a 1 August 2003 letter to the Disability Determination
Services in Timonium, Maryland, a doctor at the “Dimensions For
Fulfillment” stated that the applicant felt helpless and hopeless as
evidenced by his diagnosis of PTSD and depression, and that there was no
doubt that he was seriously injured, as well as suffering significant
emotional stress as a direct result.
bb. In a 20 August 2003 medical report prepared for the Department of
Social Services, his physician diagnosed the applicant with mild traumatic
brain injury, right motor neuropathy, neck pain, divergence insufficiency,
diplopia, back pain, and memory loss. She stated that he had been
diagnosed with PTSD, major depression, pain disorder, insomnia, headaches,
back pain, and blurred vision.
cc. The applicant underwent an MRI of his brain on 22 October 2003.
The MRI showed a retention cyst right maxillary sinus and changes of
chronic sinusitis, both ethmoid sinuses. No other abnormality was seen.
An MRA of circle of willis was normal.
dd. In a 8 January 2004 letter to the Social Security Administration
the applicant’s civilian physician provided that agency with the status of
his medical conditions and symptoms, the medications that he was on, his
physical limitations, the tests that he had undergone, the names of doctors
and therapists who have treated him, and his physical abnormalities and
diagnoses. She stated that based on her evaluation, his condition had
lasted and could be expected to last at least 12 months.
ee. On 2 February 2004 a psychologist at the Christian Counseling
Center of Annapolis, Inc. advised the U.S. Capitol Police that because of
the applicant’s limitations to his level of functioning both physically and
mentally, he could not be meaningfully employed.
ff. On 16 March 2004 the applicant underwent an operation to repair
the right perilymphatic fistulae of the oval and round windows. After the
operation he was taken to the recovery room in satisfactory condition with
normal facial function.
22. In a 24 August 2003 letter to a Member of Congress (MC) the applicant
complained of his treatment by the Maryland Army National Guard. He stated
that he suffered from mild traumatic brain injury; had reduced motor speed;
impaired vision; damage to his neck; severe nerve muscle, ligament and
tendon damage to his back; and that he suffered from PTSD, depression,
anxiety, obsessive compulsive disorder, and other psychological disorders.
a. He stated that he was treated at the Sinai Trauma Unit and
released and was told to follow up with his personal doctors by Captain “G”
until he was able to get him an appointment at WRAMC. He followed up with
his personal doctors, even after 10 April 2001, when Captain “G” informed
him that the MDARNG (Maryland Army National Guard) was not going to pay for
his civilian doctors. Captain “G” did not get him an appointment at Walter
Reed until 6 November 2001.
b. Because his LOD report that he took to WRAMC on 6 November 2001
only indicated that his elbow and left ribs were injured, that is all they
could treat him for, informing him that in order to be treated for other
injuries he would have to have another LOD indicating those injuries.
Captain “G” stated that unless he was directed he would not write an
additional LOD.
c. He was seen one other time at WRAMC, on 21 August 2002, at which
time his lawyer and LTC “J” (a WRAMC doctor) agreed that he would not have
an evaluation, but only complete documents necessary for future
appointments to treat his injuries. When he arrived at WRAMC appointments
had been scheduled to get his elbow evaluated and to see a psychiatrist.
He refused to be seen per the agreement. He did complete the paperwork.
d. He was placed on the ADME on 21 August 2002 and began receiving
pay. He was told that he would be contacted to schedule appointments;
however he was never contacted and on 17 January 2003 he no longer received
pay. LTC “J” stated that it was his wife’s responsibility to schedule
appointments; however, his wife and Sergeant “R” remained in contact
throughout the six-month period, and he never said anything to his wife
about appointments.
e. He requested that the MDARNG pay for all his past and future
medical treatments and medications, reimburse him for all his expenses,
insurance premiums and so forth.
23. In response to an inquiry from the above-mentioned MC, the Chief of
Staff, State of Maryland Military Department stated that the civilian
medical bills that the applicant incurred pursuant to his treatment for a
contusion to his right elbow and bruised ribs were paid. He stated that
when the applicant complained about recurring headaches, an examination at
WRAMC was set up to evaluate his claim on 6 November 2001; however, to date
no documents from the applicant were received regarding the assessment. He
stated that the applicant elected to seek civilian medical care and was
diagnosed with post-traumatic stress, depression, anxiety, and severe pain
resulting from his injuries, and such a claim would require a further line
of duty determination, which in turn would necessitate a military medical
evaluation. In an effort to assist him, he was placed on the ADME to
enable the military medical system to evaluate him, and to confirm the
findings of his civilian physician. Appointments were scheduled for him
with a psychologist and an orthopedic surgeon at Walter Reed; however, the
applicant consistently refused to be evaluated by those physicians. Absent
such an evaluation, a determination concerning the veracity of his alleged
medical conditions could not be made, and if substantiated, whether such
conditions were incurred in the line of duty. His ADME orders were
terminated on 19 April 2003 and his contractual service with the MDARNG
ended.
24. On 6 December 2003 the applicant submitted a 6-page rebuttal to the
above-mentioned letter. He stated that he suffered a second injury when he
reported for weekend drill on 16 March 2002 when a Soldier hit him on the
back, sustaining a second whiplash injury. He suffered vertigo and blacked
out. He was seen by Doctor “Y” who extended his temporary profile for six
months.
a. He stated that when he reported to WRAMC on 21 August 2002, he
was there only to do paperwork, per agreement between LTC “J” and his
lawyer. Doctor “X” agreed, however, that he did not need to be seen for his
elbow injury. That doctor reviewed his medical documents and completed the
Military Physician’s Statement of Soldier’s Incapacitation/Fitness for Duty
form. He stated that Sergeant “R” told him to continue seeing his civilian
doctors, and noted that on his request for ADME status.
b. He stated that he had his elbow evaluated by Doctor “C” at WRAMC
on 6 November 2001, and was informed that the paperwork [evaluation] would
be sent to his unit. Neither the MDARNG nor his unit has ever requested
the information from him.
c. He was informed on 10 April 2001 by Captain “G” that the MDARNG
would not pay for his civilian doctors. Doctor “D,” an orthopedic
specialist, informed him that he needed to wear an orthotic hinged arm
brace for six weeks until a tear in his right elbow healed. The National
Guard refused to pay for the brace and he had to pay for it. The MDARNG
did not get him an appointment to see a military doctor until 6 November
2001 even though he had informed Captain “G” of his additional injuries in
April 2001.
d. He has been evaluated by civilian doctors since 4 April 2001 for
his additional injuries. Doctor “D,” his primary care physician, suspected
head, back, and neck injuries. When Captain “G” told him to stop seeing
civilian doctors, he had already been referred to several other doctors.
He stopped seeing civilian doctors from 11 May 2001 to 31 July 2001, while
he waited for an appointment with a military doctor. Because his medical
problems worsened, he was forced to resume medical care with his civilian
doctors on 1 August 2001.
e. He was informed on 6 November 2001 that a new LOD would be needed
for him to get treated at WRAMC. Sergeant “R” informed him on 21
August 2002 that an additional LOD would be needed in order for him to be
treated for anything other than his elbow, and that he would not be seen
for additional injuries until that occurred. He stated that while on ADME,
in order for the military medical system to evaluate him and confirm the
findings of his civilian providers he would need to be seen by an array of
medical specialists.
f. He commented on the lack of cooperation by the National Guard to
set up medical evaluations at a military facility, and stated that he
needed to be evaluated by the proper military doctors, and needed an
additional LOD before he was able to be seen at WRAMC. He stated that his
primary care physician saw him 10 days after his injury, he has continued
under her care, and she has recorded his symptoms and diagnoses to the
present time. He also had numerous civilian medical providers that have
documented his medical conditions. He stated that he has been and was
still willing to be evaluated by military doctors for his additional
injuries.
25. In a nine page document dated 1 December 2003 the applicant commented
on how his mild traumatic brain injury, post concussive syndrome affected
his daily living. In a two page paper with that same date he commented on
how his neck injuries/whiplash injuries affected him. He commented on how
his back injuries affected him. In a three page document he stated that
psychologically he suffered from posttraumatic stress, depression, anxiety,
panic attacks, obsessive compulsive disorder, agoraphobia, anhedonia, and
TMS; and commented on how these conditions affected him and his life.
26. Army Regulation 635-40, chapter 8, outlines the rules for processing
through the disability system Soldiers of the Reserve component who are on
active duty for a period of less than 30 days or on inactive duty training;
and outlines the criteria under which Soldiers of the Reserve component,
whether or not on extended active duty, apply for continuance in the active
Reserve.
27. Paragraph 8-2 states that Soldiers of the Reserve components are
eligible for disability processing from an injury determined to be the
proximate result of performing annual training, active duty special work,
active duty for training, etc.
28. Paragraph 8-6 states that when a commander believes that a Soldier not
on extended active duty is unable to perform his duties because of physical
disability, the commander will refer the soldier for medical evaluation.
29. Office of the Deputy Chief of Staff, G-1 Memorandum, subject:
Retaining Reserve Component (RC) Members on Active Duty Medical Extension
(ADME) provides for the retention of Reserve Component members on active
duty when an injury or illness occurred in the line of duty, and which
prevents the Soldier from performing his/her normal military duty. All
Reserve Component Soldiers who are on active duty orders or are in an
inactive duty status and require medical treatment/evaluation for more than
30 days (inpatient or outpatient), fall under the rules, regulations, and
specified entitlements for active duty personnel.
a. Soldiers eligible for ADME status are those requiring treatment
or evaluation for 30 days or more for an injury, illness, or disease
incurred or aggravated in the line of duty.
b. The MTF (medical treatment facility) is responsible for providing
evaluation and expeditious treatment of the Soldier, and to determine
whether an individual meets medical retention standards.
c. The gaining unit where the ADME will perform “duty” will ensure
the Soldier reports for all medical appointments and follows the prescribed
medical regimen. The ADME Soldier is required to report for all medical
appointments unless circumstances clearly beyond his control prevent
keeping appointments and the appropriate authority has approved changes.
30. Army Regulation 135-381 and title 37, U.S. Code, section 204, provides
for continuation of pay and allowances under certain circumstances to
reservists who are disabled in line of duty as a direct result of the
performance of their duties. To receive continuation of pay, referred to
as incapacitation pay, reservists must either be unable to perform their
normal military duties or be able to show a loss of nonmilitary income. If
the reservist continues to work at his or her civilian job, the amount of
money earned is deducted from the incapacitation pay. Entitlement to
incapacitation pay is limited to 6 months unless the Secretary of the Army
finds that it is clearly in the interest of fairness and equity to extend
the incapacitation pay. Only in the most meritorious cases will
incapacitation pay be extended past the 6-month limitation.
DISCUSSION AND CONCLUSIONS:
1. The applicant sustained bruises to his right elbow and left lower rib
area on 25 March 2001. His injuries were in line of duty. He was seen,
evaluated, and treated for his injuries. On 27 March 2002 an orthopedist
stated that he had a contusion to his right elbow. He could do light duty,
but no heavy use of his right upper extremity for two weeks.
2. On the next day he completed a disability counseling statement,
agreeing to certain conditions, e.g, that he could not seek medical care
without receiving approval of his unit, that he had to report for any
medical appointment and to cooperate fully with medical personnel, and that
he had to furnish his unit documentation on the results of his medical
appointments.
3. On 22 May 2001, in preparation for requesting incapacitation pay, he
completed a form agreeing to certain conditions, to include receiving
written authorization from a military medical facility before obtaining
medical treatment from any civilian source or to be personally responsible
for any charges, and to submit to all military medical treatment including
reporting for medical fitness examinations. Prior to that date, on 18
April 2001, as indicated by an e-mail he sent to his commanding officer, he
was informed that he could no longer see his civilian doctor.
4. Leave and earnings statements from his employer, the United States
Capitol Police, show that he did work for a goodly portion during two week
pay periods in April and May 2001. He stated in an e-mail to his
commanding officer that his civilian physician had cleared him to return to
work full duty on 10 May 2001. Obviously, however, he was working prior to
that date.
5. In August 2001 the applicant submitted incapacitation pay monthly claim
forms, verified by the United States Capitol Police, indicating the dates
that he was not able to work - during certain periods in March, April, and
in one day in May 2001. However, some of those dates claimed appear to
conflict, with the list provided by the United States Capitol Police, e.g.,
claims for incapacitation pay for scheduled day off, and claims for
incapacitation pay for dates after his employer stated that he was returned
to duty. There is no evidence that the applicant received incapacitation
pay or even that his requests were received or processed by his commander,
and there is insufficient evidence to determine his entitlement to
incapacitation pay. Consequently, his request in this respect cannot be
granted.
6. As indicated by the e-mail traffic between the applicant and members of
his unit, he was frustrated because of the problems in getting his medical
bills paid and by the delay in being seen by a military physician. It
appears that his unit members were trying to help him in both of these
areas. The evidence shows that TRICARE paid a portion of his medical
bills. The Chief of Staff, MDARNG has indicted that his civilian medical
bills that he incurred for his treatment for a contusion to his right elbow
and bruised ribs were paid. Exactly what medical bills and expenses that
he wants the Army to pay cannot be determined by the evidence that he
submits. Nonetheless, the Board is not in a position to adjudicate his
claimed medical expenses. In this respect, the applicant should contact
the TRICARE office nearest where he lives, for information and advice
concerning any medical expenses he feels that he is due.
7. The applicant did see a military doctor on 7 November 2001 at WRAMC for
the contusion to his elbow. Prior to that date, the applicant underwent
numerous evaluations and clinical investigations, e.g., MRI of his right
elbow, CT scan of his brain, abdomen, and pelvis, examination by a
rheumatologist for his complaints of joint pain, fatigue and rash, etc.
Obviously, because his injuries were determined to be only to his elbow and
his ribs, some of those evaluations were of his own volition. There is no
evidence and the applicant has not provided any to show that he was
authorized to receive treatment for any conditions other than his elbow and
his rib area.
8. The applicant stated that he was injured further when he was hit on the
back when he reported to his unit on 16 March 2002. He did receive a
temporary profile on that date from a National Guard doctor who stated that
the applicant was awaiting paperwork to continue his evaluation, and that
in the meantime he was being seen by his civilian physician. The
applicant, however, has not provided any evidence concerning his injury on
16 March 2002.
9. The applicant’s civilian physician, in October 2001, advised WRAMC of
the applicant’s medical conditions, and stated that he had numerous
evaluations and examinations, and that all his symptoms began after his
accident, however, there was no clear diagnosis. Since that time, and
until he was placed on ADME, he continued his evaluations, for instance –
MRI of the cervical spine, chest x-ray, neurological examination, eye
examination, evaluation by a psychologist, a chiropractor, an orthopedist,
etc. He has been diagnosed with headaches, vertigo, PTSD, cervical and
lumbar strain, chest pain, insomnia, depression, neck and back pain,
blurred vision, fatigue, and so forth, as well documented in the medical
reports submitted with his request. At least two of the specialists who
evaluated him stated that his condition resulted from his accident on 25
March 2001.
10. By the same token, however, a psychologist stated that the applicant
was responding to stress by developing physical symptoms, and that many of
the symptoms he reported were indicative of a conversion disorder – that
there was no basis for the number of complaints that he had.
11. On 21 August 2002 the applicant requested an extension on active duty
to receive medical treatment for his injuries. Apparently, on that same
date a doctor at WRAMC indicated that the applicant needed to be seen and
evaluated by a neurologist/psychologist for medical issues not diagnosed by
a medical treatment facility for follow up care and a possible MEB/PEB.
The applicant himself stated in a letter to a MC that he had been scheduled
for an appointment at WRMAC to get his elbow examined and to see a
psychiatrist; however, based on the advice of his attorney, he refused to
be seen.
12. In November 2002 the applicant sustained an injury to his head, neck,
and shoulder area while sitting in a movie theater. He was treated for
those injuries and continued to be treated and evaluated for his other
conditions, both prior to and after this discharge from the Army National
Guard.
13. The applicant was on ADME from 21 August 2002 until 17 January 2003
for the sole purpose of receiving medical treatment and evaluation for his
numerous complaints. However, even on the date that he himself requested
to be placed on the ADME, he refused treatment. Thereafter, he did
nothing, although he stated that he was told that appointments would be
made for him. He received active duty pay for approximately five months,
without being treated or evaluated for the numerous medical conditions that
he was diagnosed with from the date of his injury in March 2001.
14. The evidence shows that the applicant sustained minor injuries to his
elbow and lower left rib area, that he was treated for those injuries, and
that his medical bills that he incurred because of those injuries were
paid. He took it upon himself to seek and receive treatment for other
conditions, none of which have been shown to be related to his accident on
25 March 2001, despite the myriad workups that he has received. He had the
opportunity to be evaluated for his complaints, and if necessary be
referred to a MEB/PEB, but he did nothing. Absent any evaluation to
determine his medical condition, he could not be referred to a MEB/PEB. He
was discharged from the Army National Guard on the expiration of his term
of service.
15. There is no evidence and the applicant has not submitted any to show
that his numerous physical disabilities were a result of the 25 March 2001
accident. He was treated for his line of duty injuries. He has provided
no probative evidence or any good argument to grant his request for further
ADME or to grant his request for physical disability retirement or
separation.
16. Noted is the applicant’s request to correct his NGB Form 22. The
evidence shows that his first and middle names on that form are reversed.
The other corrections that the applicant requests cannot be verified from
the available evidence. Nonetheless, The Office of the Judge Advocate
General has opined in previous cases that this Board is empowered to change
records of the Department of the Army and has no jurisdiction to change
state records of the Army National Guard. This determination appears to
apply to the portion of the applicant’s request concerning correction of
his NGB Form 22. Consequently, the applicant should apply to the MDARNG to
correct information on that form.
BOARD VOTE:
________ ________ ________ GRANT FULL RELIEF
________ ________ ________ GRANT PARTIAL RELIEF
________ ________ ________ GRANT FORMAL HEARING
___RW__ ___LB___ ___LO __ DENY APPLICATION
BOARD DETERMINATION/RECOMMENDATION:
The evidence presented does not demonstrate the existence of a probable
error or injustice. Therefore, the Board determined that the overall
merits of this case are insufficient as a basis for correction of the
records of the individual concerned.
____ Raymond Wagner______
CHAIRPERSON
INDEX
|CASE ID |AR20040003121 |
|SUFFIX | |
|RECON |YYYYMMDD |
|DATE BOARDED |20050419 |
|TYPE OF DISCHARGE |(HD, GD, UOTHC, UD, BCD, DD, UNCHAR) |
|DATE OF DISCHARGE |YYYYMMDD |
|DISCHARGE AUTHORITY |AR . . . . . |
|DISCHARGE REASON | |
|BOARD DECISION |DENY |
|REVIEW AUTHORITY | |
|ISSUES 1. |100.00 |
|2. |108.00 |
|3. | |
|4. | |
|5. | |
|6. | |
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