BOARD DATE:	  23 October 2012

		DOCKET NUMBER:  AR20120006869 


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 additional Traumatic Servicemembers' Group Life Insurance (TSGLI) pay for 90 and 120 days of Activities of Daily Living (ADL) loss.

2.  The applicant states she experienced ADL losses in at least two categories for over 120 days.  She states her ADL claims were denied in spite of meeting the criteria for payment of benefits.  

3.  The applicant provides the documents listed in item 9 (In support of this application, I submit as evidence the following attached documents) in support of her request.  

CONSIDERATION OF EVIDENCE:

1.  The applicant's record shows she enlisted in U.S. Army Reserve (USAR) on 27 May 1982, and continues to serve in a Reserve Component (RC) through the present. 

2.  On 22 January 2010, while on the way to duty, the applicant was involved in a motor vehicle accident that resulted in compound fractures to her left leg. 

3.  Operative reports provided by the applicant show she underwent surgery based on a diagnosis of fractured left tibial plafond comminuted on 24 January 2010.  The discharge summary portion of the operative report indicates she was doing well and was discharged to home on 26 January 2010.  
4.  A medical summary letter, dated 27 April 2010, from the applicant’s doctor indicates the tibial fracture was well aligned and the applicant was going to be started on some partial weight-bearing with walker protection.  It indicated she continued to need maximum support for bathing, getting her clothes on and off, etc.   

5.  The applicant’s TSGLI claim summary shows she originally submitted her claim in March 2010, which was approved for 30 days ($25,000) for ADL loss.  She submitted a second application for additional ADL which was denied twice due to a lack of documentation.  In June 2010, her appeal for additional time for ADL loss was approved for an additional 30 days ($25,000), which totaled payment for 60 days of ADL loss ($50,000).  

6.  In January 2011, the applicant applied for additional time for ADL loss.  This request was denied based on the applicant not meeting the standard for ADL loss beyond the 60 days paid.  She appealed this decision in March 2011 and this appeal was also denied with a notation the applicant was using adaptive equipment to perform ADLs.  

7.  In October 2011, the applicant’s final appeal for additional payment for loss of ADL was denied.  Doctor’s indicated the applicant's injury involved a serious single limb injury, without complications, in an otherwise uninjured Soldier then there is justification for up to 60 days of ADL loss.  It is a reasonable expectation that the Soldier is capable of adopting, by 60 days post injury, adaptive behaviors to accomplish all activities of daily living in a modified independent manner in coping with a single limb injury.  The doctor indicated the recommendation was for 60 days of ADL loss.  

8.  Public Law 109-13 (The Emergency Supplemental Appropriations Act for Defense, the Global War on Terror, and Tsunami Relief 2005) signed by the President on 11 May 2005 established the TSGLI program.  U.S. Army Combat- Related Special Compensation office has been designated as the lead agent for implementing the Army 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.

9.  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 $1.00 deducted each month to cover the cost of the TSGLI policy.  Soldiers paying for SGLI coverage cannot decline TSGLI -- it is a package.
10.  In addition, there is a retroactive program in which Soldiers who incurred a qualifying traumatic injury between 7 October 2001 and 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 (Active, Reserve, or National Guard) or the location in which they incurred the injury, will be covered by TSGLI.

11.  Other traumatic injuries resulting in the inability to carry out two of the six ADL, which are dressing, bathing, toileting, eating, continence, and transferring. TSGLI claims may be filed for loss of ADL if the claimant is completely dependent on someone else to perform two of the six ADLs for 30 days or more (15 days or more in the case of traumatic brain injuries).  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 will not be approved without a certification from a healthcare provider, additional documentation must be provided to substantiate the certification.

12.  Appendix B (Glossary of Terms) of the TSGLI Procedures Guide, dated September 2008, provides the following definitions:

	a.  Traumatic Event, the application of external force, violence, chemical, biological, or radiological weapons, accidental ingestion of a contaminated substance, or exposure to the elements that causes damage to a living body. Examples include:

* Military Motor Vehicle Accident
* Military Aircraft Accident
* Civilian Motorcycle Accident

	b.  Traumatic Injury, the physical damage to a living body that results from a traumatic event.

	c.  External Force, as a force acting between the body and the environment, including a contact force, gravitational force, or environmental force, or one produced through accidental or violent means.

13.  A member who is hospitalized 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 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 other traumatic injury.

14.  Army Regulation 15-185 (Army Board for Correction of Military Records) prescribes the policies and procedures for correction of military records by the Secretary of the Army acting through the ABCMR.  This regulation provides that the ABCMR begins its consideration of each case with the presumption of administrative regularity.  The applicant has the burden of proving an error or injustice by a preponderance of the evidence.

DISCUSSION AND CONCLUSIONS:

1.  The applicant’s request to be provided additional TSGLI payments for 120 days of ADL loss has been carefully considered.  However, there is insufficient evidence to support this claim.  

2.  The evidence of record confirms a reviewing physician verified that there is a reasonable expectation that a Soldier with a single limb injury with no complications would be capable of adopting, by 60 days post surgery, behaviors to accomplish all ADLs in a modified independent manner.  The doctor indicated the recommendation was for 60 days of ADL loss.  Given this medical expectation, and the fact the applicant was in fact paid for 60 days of ADL loss, the independent evidence provided by the applicant is not sufficiently compelling to support additional ADL loss payments beyond the 60 days already paid.  

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)                                         AR20120006869



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ABCMR Record of Proceedings (cont)                                         AR20120006869



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