IN THE CASE OF:	  

		BOARD DATE:	  27 September 2011

		DOCKET NUMBER:  AR20110012631 


THE BOARD CONSIDERED THE FOLLOWING EVIDENCE:

1.  Application for correction of military records (with supporting documents provided, if any).

2.  Military Personnel Records and advisory opinions (if any).


THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE:

1.  The applicant requests, in effect, that his Traumatic Servicemembers’ Group Life Insurance (TSGLI) claim for hospitalization due to a traumatic brain injury (TBI) be reconsidered. 

2.  The applicant states that in March 2006 he was wrongfully denied TSGLI benefits.  His May 2011 resubmission was also denied. 

3.  The applicant provides the following additional documentary evidence:

* Denial letter from the U.S. Army Human Resources Command, Fort Knox, KY (HRC-KNX), dated 16 May 2011
* Denial letter from the Office of Servicemember's Group Life Insurance, Livingston, NJ, 4 May 2006
* TSGLI application and allied medical records
* Department of Veterans Affairs (VA) rating decision and allied medical documents

CONSIDERATION OF EVIDENCE:

1.  The applicant enlisted in the Pennsylvania Army National Guard (PAARNG) on 31 January 1985 and held military occupational specialty (MOS) 11B.  He served through multiple extensions or reenlistments and he was honorably discharged on 30 January 1997. 

2.  After a break in service, he enlisted in the PAARNG on 24 March 1998 and held MOS 12B (Combat Engineer).  He attained the rank/grade of sergeant (SGT)/E-5.  

3.  On 24 July 2002, he was ordered to active duty and subsequently served in Bosnia from 25 August 2002 to 16 March 2003.  He was honorably released from active duty on 14 April 2003.

4.  He was ordered to active duty on 28 June 2004 in support of Operation Iraqi Freedom.  He arrived in Kuwait/Iraq on 1 December 2004. 

5.  On 4 August 2005, he was a gunner in a vehicle, part of a convoy, in a platoon that was conducting combat operations in Iraq.  An improvised explosive device (IED) detonated to the left side of his vehicle.  He blacked out for a few seconds and was slow to respond to the medics.  After returning to the forward operating base, the doctors told him he had a concussion from the blast.

6.  He departed Kuwait/Iraq on 27 October 2005.  On 20 March 2006, the applicant completed and submitted his application for TSGLI benefits.  He claimed he suffered a traumatic injury due the explosion and the loss of other activities of daily living (ADL) for 30 days due to a back injury.  It is unclear what ADLs he claimed.  Additionally, the attending physician (VA staff psychiatrist) signed the form but did not provide any input.

7.  On 4 May 2006, an official at the Office of Servicemember's Group Life Insurance, Livingston, NJ, notified the applicant that his application was denied because there was no evidence that he incurred a covered loss.  

8.  On 6 January 2011, a VA medical doctor certified his TSGLI application and indicated that the applicant was first evaluated by the Philadelphia VA Medical Center on 23 July 2007 and since that time he has worked with a multidisciplinary team in the management of his TBI.  The doctor also indicated the applicant had a significant TBI compounded by pronounced post-traumatic stress disorder (PTSD) symptoms.  On 9 February 2011, the applicant resubmitted his TSGLI application.  He claimed he had been hospitalized for TBI from 17 February to 20 March 2009.  He did not claim ADL loss.

9.  On 16 May 2011, by letter, an HRC-KNX official notified the applicant that after reviewing his claim and the supporting documentation, there was insufficient evidence to overturn the previous adjudication.  Additionally, his hospitalization was not within the 730 days/2 years standard from the date of his traumatic injury.

10.  Public Law 109-13, signed by the President on 11 May 2005, established the TSGLI program.  The TSGLI program was established by Congress to provide relief to Soldiers and their families after suffering a traumatic injury.  TSGLI provides between $25,000.00 and $100,000.00 to severely injured Soldiers who meet the requisite qualifications set forth by the Department of Defense.  A qualifying traumatic injury is an injury or loss caused by a traumatic event or a condition whose cause can be directly linked to a traumatic event.  The HRC official TSGLI website lists two types of TSGLI losses, categorized as Part I and Part II.  Each loss has a corresponding payment amount.

	a.  Part I loss includes sight, hearing, speech, quadriplegia, hemiplegia, uniplegia, burns, amputation of hand, amputation of four fingers on one hand or one thumb alone, amputation of foot, amputation of all toes including the big toe on one foot, amputation of big toe only, or other four toes on one foot, limb salvage of arm or leg, and facial reconstruction.  

	b.  Part II loss includes traumatic injuries resulting in the inability to perform at least two ADLs for 30 or more consecutive days and hospitalization due to a traumatic injury and other traumatic injuries (OTI) resulting in the inability to carry out two of the six ADLs, which are dressing, bathing, toileting, eating, continence, and transferring.  TSGLI claims may be filed for loss of ADLs if the claimant is completely dependent on someone else to perform two of the six ADLs for 30 days or more. ADL loss must be certified by a healthcare provider in Part B of the claim form and ADL loss must be substantiated by appropriate documentation such as occupational/physical therapy reports, patient discharge summaries, or other pertinent documents demonstrating the injury type and duration of ADL loss.

11.  A member who is hospitalized for 15 consecutive days as the result of a traumatic injury is eligible for a $25,000.00 payment under TSGLI.  The count of consecutive hospitalization days begins when the injured member is transported to the hospital, includes the day of admission, continues through subsequent transfers from one hospital to another, and includes the day of discharge.  If a member is hospitalized for 15 consecutive days, the member's hospitalization takes the place of the first ADL milestone payment only.  The 15 days of hospitalization cannot be substituted for any other ADL milestone payment.  Payment will be made for the 15-day hospitalization or the first ADL milestone, whichever occurs first.  There are two situations covered by this replacement:  the member is hospitalized due to coma/TBI or the member is hospitalized due to OTI.



DISCUSSION AND CONCLUSIONS:

1.  The applicant was injured on 4 August 2005.  He applied for TSGLI benefits on 20 March 2006.  He claimed that he suffered a concussion and a back injury on 4 August 2005 but he did not submit any evidence to show he incurred a covered loss.  His claim was reviewed by officials at the Office of Servicemembers' Group Life Insurance who determined that he did not incur a covered loss and accordingly denied his claim.  

2.  In January 2011, a VA doctor certified his TSGLI application and indicated the applicant was first evaluated by the VA medical center on 23 July 2007, more than 730 days after his 4 August 2005 injury.  The VA doctor did not indicate the applicant incurred a covered loss at that time.

3.  It appears that he was hospitalized from February to March 2009.  He resubmitted his claim in January 2011 and this time he claimed TBI loss, but he did not claim any ADL loss.  

4.  By law, in order to be eligible for TSGLI benefits for a traumatic injury, the loss must be a direct result of a traumatic event and no other cause and the member must suffer a loss covered under the law within 730 days of the traumatic event.  The applicant has not provided sufficient documentation to show that he suffered a covered loss within 730 days of his 4 August 2005 injury.  Neither the available records nor the medical documentation the applicant provided establish a basis to support his request.  

BOARD VOTE:

________  ________  ________  GRANT FULL RELIEF 

________  ________  ________  GRANT PARTIAL RELIEF 

________  ________  ________  GRANT FORMAL HEARING

___X____  ___X___  ___X____  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.



      _______ _  X______   ___
               CHAIRPERSON
      
I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case.

ABCMR Record of Proceedings (cont)                                         AR20110012631



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ABCMR Record of Proceedings (cont)                                         AR20110012631



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