BOARD DATE:	  6 March 2014

		DOCKET NUMBER:  AR20130020944 


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 the remaining 30th and 60th day payments under the provisions of the Traumatic Servicemembers Group Life Insurance (TSGLI).

2.  The applicant states:

   a.  On 3 July 2013, his claim was approved for $25,000 for the first 15 days of the loss of activities of daily living (ADL) due to a traumatic brain injury (TBI).  However, the remaining 30th and 60th consecutive day payments were denied even though they were substantially validated by his primary care physician along with the provided supporting documentation.

   b.  In accordance with the TSGLI procedural guidance, TSGLI benefits will be paid based on the number of consecutive days the member has loss of ADL due to TBI.  The duration of the loss of ADL included the date the member began to be unable to perform the ADL and the date the member was again able to perform the ADL.  Payment of loss of ADL due to TBI will be as follows:

* $25,000 at the 15th consecutive date
* an additional $25,000 at the 30th consecutive day
* an additional $25,000 at the 60th consecutive day
* an additional $25,000 at the 90th consecutive day

   c.  Upon the original submission of his claim he presented three losses of ADL due to TBI lasting a period of 78 days.  He was unable to bathe, dress, and eat independently from 8 January to 25 March 2012.  The ADLs were validated and certified by his primary physician, Dr. Jxxxxxxx R. Sxxxxxx, on form SGVL 8600 (Member's Claim Information and Authorization) on 7 June 2012.  He additional provided substantiating documents in support of the claimed ADLs.

   d.  All the criteria were met and validated in accordance with the TSGLI procedural guidance; however, it appears that only the initial 15-day ADL/TBI payment was given.  The remaining 30th and 60th day threshold payments were ignored.  The same form SGLV 8600 which was used in determination and validation of ADLs losses also included the through dates validated by his primary physician.  Therefore, it appears that the remaining 30th and 60th day threshold were arbitrarily denied with no justification to support denial. 

   e.  He requests approval for the remaining benefits of the 30th and 60th consecutive day payments as he has met the contractual and legal criteria as set forth by the regulation and program requirements.

3.  The applicant provides copies of the following:

* four Progress Notes
* Memorandum for Record (MFR)
* SGLV Form 8600
* letters from his neurologist and the U.S. Army Human Resources Command (HRC)

CONSIDERATION OF EVIDENCE:

1.  The applicant was appointed in the U.S. Army Reserve, as a second lieutenant, on 6 July 2003 and entered active duty on 27 September 2004.

2.  He provided copies of the following:

	a.  Four Progress Notes, dated 2 and 13 February and 7 and 8 March 2013, which show the applicant's short-term goal was the forced use of his left hand at home and to challenge and strengthen visual-perceptual skills.

	b.  A MFR, dated 6 March 2013, wherein the battalion surgeon, 10th Special Forces Group (Airborne), stated that on 8 January 2012 the applicant sustained a life threatening stroke due to a right carotid artery dissection sustained while performing combatives.  The applicant was initially hospitalized for three days followed by 90 days convalescent leave (11 January to 11 April 2012).  He extended the applicant's convalescent leave for two weeks while the applicant was waiting to be cleared to drive by the TBI clinic.  He returned the applicant to limited duty three times weekly for three weeks to allow him to complete physical and occupational therapy as part of his post-stroke rehabilitation.  The applicant was returned to full duty on 16 May 2012.  Since his stroke, the applicant was able to resume full duties without limitations.

	c.  An SGLV 8600 which shows in Part B (Medical Professional's Statement) the applicant's primary care physician completed and validated on 7 June 2012 and stated that the applicant was unable to independently bathe, dress, and eat from 8 January through 25 March 2012.  After his stroke the applicant had difficulty with basic activities.  He was unable to drive secondary to his vision loss.  He had since returned to driving.  He needed help with dressing because he incorrectly put on clothes and was intermittently coughing with eating.  He had loss of sensation of the left hemi body.  It seemed he had a degree of neglect because he also had difficulty shaving the left side of his head.  In general, he was doing better, but had substantiating deficits early in his course.

	d.  A letter from Dr. Sxxxxxx, dated 17 August 2013, which stated that the applicant and his wife described to him the difficulty with eating, dressing, and the required assistance from the applicant's wife after his stroke.  He did not recall being told about the applicant's difficulty in the shower, but given the extent of his neglect, it was reasonable to assume that he also had difficulty showering.  Therefore, he believed the applicant had impairment of his ADLs in dressing, bathing, and eating.  His last clinic visit with the applicant occurred on 10 May 2012, shortly after his last therapy visits.

   e.  A letter from HRC, dated 10 September 2013, wherein the Chief, Special Compensation Branch, advised the applicant that their records indicated his most recent claim was reviewed by the TSGLI Appeals Review Panel, which was the highest level of appeal within the TSGLI office.  With his subsequent submission received on 10 September 2013, he submitted no new or substantive evidence nor was any new losses certified which had not previously been reviewed.  He was referred to submit any further appeals to the Army Review Boards Agency or he had the right to file suit in Federal court to contest an adverse TSGLI decision. 

3.  His record contains a TSGLI Medical Consultant Physician Write-up which stated the following:

   a.  The applicant sustained a few head blows during combative training.  Three days later he suffered a right middle cerebral artery (R MCA) ischemic stroke.  He was treated rapidly and appropriately; both his clots were removed within hours.  At the point, he had mild left hemiparesis, partial left hemianopia, and mild cognitive impairment (CI).  Cardiopathy and coagulopathy were both ruled out.  He was hospitalized from 8 to 10 January 2012 and was discharged to home after the stroke.
   b.  The neurologist discharge (DC) summary noted that the applicant was making great and rapid gains.  Both summaries (by neurosurgery and neurology [Dr. Sxxxxxx]) diagnosed an R MCA right cerebrovascular accident (CVA) secondary to a renal cell carcinoma pseudoaneurysm (a hematoma that forms as the result of a leaking hole in an artery).  Dr. Sxxxxxx advised against driving and returning to work, implying that the applicant was fairly capable, certainly of ADLs.  Neither summary mentioned the claimed TBI traumatic encephalopathy (TE), or posited trauma as contributory or causative.  The applicant was to follow-up with a Dr. Exx in 3 to 4 weeks.  The applicant continued to improve rapidly, but remained on convalescent leave for 90 days due to subtle deficits and therapy.

   c.  A 10 February 2012, as noted by the applicant's primary care physician, 33 days after the TE, the applicant reported no eye or musculoskeletal symptoms.  His neurosurgeon, Dr. Sxxxxxxx, on day 39 after TE and day 37 after hospitalization, stated that the applicant was almost normal and the only etiology was a very, very small out pouching or pseudoaneurysm from the RCC origin.  Again, he did not mention the claimed TE or posit trauma as contributory or causative.  Dr. Sxxxxxxx also wrote that the applicant understood he would no longer be able to jump from airplanes.

   d.  On 11 May 2012, 4 months after the CVA, Dr. Sxxxxxx wrote similarly, stating that the applicant was essentially back to baseline and the only possible etiology identified was a pseudoaneurysm which was small.

   e.  The applicant claimed loss of three ADL-TBI (dress, bathe, eat) for 77 days following his stroke.  He suffered a right sided-stroke, resulting in mild left hemiparesis, partial hemianopia, and mild CI, from which he recovered fairly rapidly.  The cause of the applicant's stroke was unknown with any certainty.  His doctors initially cited medical risk factors.  They made no note of a traumatic etiology for seven months and never mentioned the claimed TE.  Nevertheless, he agreed that the injury probably caused the pseudoaneurysm which formed the clots, which dislodged, causing the CVA. 

   f.  No evidence was submitted describing the applicant's ADL capabilities at day 15 or 30, but the hospital DC summary implied that he was ADL capable by the second day CVA, certainly using his left unaffected side.  Documents did not indicate CI of severity to meet TSGLI requirements for ADL-TBI loss.  Records show the applicant continued in an outpatient status, maintaining weight.  Submitted medical documents did not indicate that the injury rendered the applicant incapable of performing the ADLs for 15 plus days, per TSGLI guidelines.  The impairments did not rise to the requirements for that scheduled loss, per TSGLI standards.  He recommended disapproval for any ADL-TBI at 15 plus days.

4.  Public Law 109-13 established the TSGLI Program 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.

5.  A member is considered to have loss of ADL if the member requires assistance to perform at least two of the six ADLs (dressing, bathing, toileting, eating, continence, and transferring).  Required assistance is defined as without the assistance, the patient would be incapable of performing the task.

6.  TSGLI claims may be filed for the loss of ADL if the claimant is dependent on someone else to perform two of the six ADLs for 30 days or more and is incapable of performing the tasks without the required assistance.  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 certificate form a healthcare provider, additional documents must be provided to substantiate the certificate.

DISCUSSION AND CONCLUSIONS:

1.  The applicant's contentions and documentation submitted were carefully considered.

2.  Discharge summaries contained no evidence describing the applicant's ADL capabilities at day 15 or 30, but implied that he was ADL capable by the second day CVA, certainly using his left unaffected side.  Documents reviewed by the TSGLI medical consultant did not indicate that his injury rendered him incapable of performing the ADLs for 15 plus days, per TSGLI guidelines and standards.

3.  There is no evidence and he did not provide sufficient evidence supporting his claim for the 30 and 60 day TSGLI payments.  By law, for an ADL loss to be covered the loss must be certified by a healthcare provider and substantiated by appropriate documentation, i.e., occupational/physical therapy reports, discharge summaries, and other medical documents.

4.  His records do not show and he did not provided evidence that his 30 and 60 day TSGLI payment were improperly disallowed.  Therefore, there is an insufficiently evidentiary basis for granting him the requested relief.

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)                                         AR20130020944





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ABCMR Record of Proceedings (cont)                                         AR20130020944



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