IN THE CASE OF:	  

		BOARD DATE:	 15 December 2012 

		DOCKET NUMBER:  AR20110017346 


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 be reconsidered.

2.  The applicant states that he was injured in 2006 and his TSGLI application has been denied on three separate occasions.  He suffered a gunshot wound on 18 July 2006 but he was told his wound did not constitute a covered loss.  The gunshot wound severed a muscle, left open entry and exit wounds, and required 2 months of convalescence.  The doctors' notes did not mention that his efforts to move, change his bandages, wash, change clothes, and use the restroom.  These were too difficult for him to do.  All medical personnel who took care of him recommended that he not do so due to the extent of his injury.  He chose to push past the threshold for an otherwise compensable wound.  Additionally, in light of the change to the TSGLI program that qualifies a member who had been hospitalized and since he was hospitalized from 18 July to 2 August 2006 
(16 days) in various facilities, he should qualify.

3.  The applicant provides a:

* 2007 denial letter from the U.S. Army Physical Disability Agency (USAPDA), TSGLI
* 2006 denial letter from the Office of Servicemember's Group Life Insurance
* Letter of support from a Wounded Warrior Advocate
* October 2010 TSGLI application
* Standard Form 502 (Narrative Summary (Clinical Résumé))
* Various chronological records of medical care, treatment records, and other medical documents

CONSIDERATION OF EVIDENCE:

1.  The applicant’s records show he enlisted in the Regular Army on 14 September 2004 and held military occupational specialties 18D (Special Operations Medical Sergeant) and 11B (Infantryman).  

2.  On 18 July 2006, he sustained a bilateral gunshot wound to his legs.  He was initially admitted and treated by undergoing surgery to clean, debride, and close the wound at the 47th Combat Support Hospital in Mosul, Iraq.  He was discharged on 19 July 2006.  He was transferred to Landstuhl Regional Medical Center (LRMC), Germany on 19 July 2006.

3.  He departed LRMC on 23 July 2006 and continued to receive care during an overnight stay, in an outpatient status, by the 60th Medical Group at Travis Air Force Base, California, on 24 July 2006.

4.  He was admitted to Madigan Army Medical Center, Fort Lewis, WA, on 25 July 2006, where he continued treatment until he was discharged on 2 August 2006.  He was subsequently placed on convalescent leave from 3 to 15 August 2006.  His injury required him to be in a straight leg brace keeping his right leg immobile for 3 weeks after the injury, followed by skin grafting surgery.  

5.  He originally submitted a TSGLI claim on 29 September 2006 but he was denied on 2 October 2006.  His original TSGLI application and response to this application are not available for review with this case.  

6.  His second TSGLI application, submitted on 15 December 2006, is also not available for review; however, a response, dated 22 December 2006, from the Office of Servicemember's Group Life Insurance, Livingston, NJ, stated that the medical documentation he submitted did not support that he incurred a covered loss.  

7.  His third appeal, submitted on 7 July 2007, is also not available for review with this case; however, a response, dated 2 August 2007, from the USAPDA, Alexandria, VA, stated that although he incurred a traumatic injury, the supporting medical documentation did not support the physician's certification of total dependence on another person for the performance of activities of daily living (ADLs) that were impacted.  The medical records showed he was ambulant while using accommodating equipment within 30 days of the injury.

8.  On 21 October 2010, the applicant completed and submitted yet another application for TSGLI benefits.  He claimed Other Traumatic Injury (OTI) and stated that he was hospitalized from 18 July to 2 August 2006 as follows:

* 18 to 20 July 2006, Combat Support Hospital
* 20 to 24 July 2006, LRMC, Germany
* 24 to 25 July 2006, Air evacuation through Travis Air Force Base
* 25 July to 2 August 2006, Madigan Army Medical Center

9.  He also claimed OTI for ADL loss for 30 days, from 18 July to 18 August 2006, due to his gunshot wound.  He claimed ADL loss due to his inability to:

* Bathe independently (needed physical assistance – hands on); he stated that he required his spouse's physical assistance as he was unable to get in or out of the bathroom due to his braces
* Dress independently (needed physical assistance – physical assistance – hands on); he stated he was unable to don pants and shoes because of the leg brace and requirement for complete immobilization of leg

10.  The medical professional stated the applicant suffered a gunshot wound to the thigh through and through; also a grazing gunshot wound to left anterior thigh of the left leg.  He was in straight leg braces 3 weeks followed by skin grafting surgery.

11.  Public Law 109-13, signed by the President on May 11, 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 and $100,000 to severely injured Soldiers who meet the requisite qualifications set forth by the Department of Defense (DOD).  As of 1 December 2005, TSGLI is included as part of a Soldier's SGLI coverage. Any Soldier who elected SGLI coverage automatically receives TSGLI coverage with an additional $1 taken out each month to cover the cost of the TSGLI policy. Soldiers paying for SGLI coverage cannot decline TSGLI--it is a package.  In addition, there is a retroactive program, in which Soldiers who incurred a qualifying traumatic injury from 7 October 2001 through 30 November 2005, while supporting Operation Iraqi Freedom and Operation Enduring Freedom or under orders in a Combat Zone Tax Exclusion area are covered regardless of whether they elected SGLI coverage or not.  Soldiers who elect SGLI coverage and incur a qualifying traumatic injury after 1 December 2005 (with the exception of some specific circumstances under which a traumatic injury will not be covered), regardless of their component or the location in which they incurred the injury will be covered by TSGLI. 

12.  There are some specific circumstances under which a traumatic injury will not be covered by TSGLI.  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.  Traumatic injuries covered may include, but are not limited to the following types of losses total and permanent loss of sight in one or both eyes, loss of hand or foot by severance at or above the wrist or ankle, total and permanent loss of hearing in one or both ears, loss of speech, loss of thumb and index finger of the same hand by severance at or above the metacarpo- phalandeal joints, quadriplegia, paraplegia or hemiplegic, third (3rd) degree or worse burns covering 30 percent of body or 30 percent of the face, and coma or traumatic brain injury.

13.  Other traumatic injuries 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 2 of the 6 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.  While TSGLI claims won't be approved without a certification from a healthcare provider, additional documentation must be provided to substantiate the certification.

14.  As the original program was being implemented, the Department of Veterans Affairs (VA) announced it would initiate a Year One Review of TSGLI.  This review would be undertaken to assure that the TSGLI program was meeting its intended purpose, that all appropriate conditions were being covered, and that the program was operating efficiently and effectively.  The VA wanted to ensure that the TSGLI program was fulfilling its mission to provide short-term financial assistance to severely-injured service members and their families and to improve the administration of the program.  The VA, in cooperation with the DOD, undertook a complete evaluation of the losses covered by the TSGLI program as well as the definitions of eligibility.  They met with and requested information from a variety of medical experts, performed independent research, made site visits to medical treatment facilities, had discussions with advocacy groups and case managers, received input from the claims processors in the branches of service, and conducted a comprehensive analysis of over 200 completed cases.  Since TSGLI was broadly modeled after Accidental Death and Dismemberment (AD&D) benefits in the commercial insurance industry, the VA also examined industry trends relating to AD&D benefits over the last 2 years.  

15.  The TSGLI legislation mandated coverage of certain specific losses:  the total and permanent loss of sight, speech or hearing, amputation of hand or foot, loss of thumb and index finger, quadriplegia, paraplegia, or hemiplegia, burns, coma, or the inability to carry out the ADLs resulting from traumatic injury to the brain.  The legislation also authorized the Secretary of the VA, in collaboration with the Secretary of Defense, to prescribe additional losses.  Selected program design changes were made part of the TSGLI regulation changes, which became effective on 26 November 26 2008.

DISCUSSION AND CONCLUSIONS:

1.  The applicant suffered a gunshot wound on 18 July 2006.  He was initially admitted to a combat hospital in Iraq on 18 July 2006 and released on 19 July 2006.  He was then treated from 19 July to 23 July 2006 in Germany.  He was evacuated from Germany and treated in an outpatient status at Travis Air Force Base from 23 to 24 July 2006.  He was ultimately admitted to Madigan Army Medical Center from 25 July to 2 August 2006.

2.  His TSGLI applications are not available for review with this case.  He submits two denial letters, one dated 22 December 2006, from the Office of Servicemember's Group Life Insurance which stated the medical documentation he submitted did not support that he incurred a covered loss.  The second, dated 2 August 2007, from the USAPDA, stated that although he incurred a traumatic injury, the supporting medical documentation did not support the physician's certification of total dependence on another person for the performance of ADLs that were impacted.  The medical records showed he was ambulant while using accommodating equipment within 30 days of the injury.

3.  With respect to the hospitalization, by law, for hospitalization loss to be covered, the member must be hospitalized as an inpatient 15 consecutive days as a result of a traumatic injury.  Although inpatient hospitalization includes transportation time from the site of the injury to the hospital, his medical record at Travis Air Force Base clearly shows he was treated in an outpatient status.  Inpatient hospitalization for less than 15 days and inpatient hospitalization for non-consecutive days are not eligible for TSGLI benefits.

4.  With respect to the ADL loss, by law, for ADL loss to be covered, the loss must be for at least 30 days, the member must require assistance to perform two of six ADLs, the ADL loss must be certified by a healthcare provider and must be substantiated by appropriate documentation such as occupational therapy/physical therapy reports, discharge summaries and other medical documentation.

	a.  The applicant has not provided sufficient documentation to support his implied contention that his TSGLI claims were improperly disallowed.  Neither the available records nor the medical documentation the applicant provided establish a basis to support his request.  The individual is considered to need assistance only if he or she requires physical (hands-on), stand-by (within arm’s reach), or verbal (must be instructed because of cognitive impairment) assistance, without which they would be incapable of performing the activity.

	b.  TSGLI analysts strive to apply a "reasonable person" standard to each claim with a bias in favor of the claimant while still maintaining a high degree of internal consistency among similar claims.  The applicant's injury pattern, a gunshot wound, is generally insufficient justification for payment of TSGLI benefits.  It is a reasonable expectation that a Soldier is capable of adopting within 30 days of injury, adaptive behaviors to accomplish all ADLs in coping with his injury. 

5.  In view of the foregoing, there is no basis for granting relief to the applicant in this case.

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)                                         AR20110017346



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ABCMR Record of Proceedings (cont)                                         AR20110017346



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