IN THE CASE OF:

		BOARD DATE:	      21 May 2014

		DOCKET NUMBER:  AR20140003976 


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 he be awarded Traumatic Servicemembers' Group Life Insurance (TSGLI) benefits.

2.  The applicant states:

* he suffered a brand new injury of the right knee that required a total knee replacement on 25 November 2013
* he had activities of daily living (ADL) loss from 25 November 2013 to 
      30 December 2014
* TSGLI is treating the injury like it's the same injury

3.  The applicant provides:

* TSGLI application
* Medical records

CONSIDERATION OF EVIDENCE:

1.  Having prior inactive service in the U.S. Army Reserve (USAR) and Army National Guard and active service in the Regular Army, the applicant enlisted in the USAR on 8 July 1989.  He was ordered to active duty on 4 December 2005 in support of Operation Iraqi Freedom.  He served as a civil affairs specialist in Iraq from 26 April 2006 to 23 April 2007.  On 30 May 2007, he was released from active duty.   

2.  He provides medical records which indicate he had arthroscopy in 2009 and cadaver repair for replacement of anterior cruciate ligament (ACL) in May 2011.

3.  He was promoted to sergeant first class on 1 January 2012.

4.  On 29 September 2013, he was retired by reason of permanent disability.

5.  He provides a TSGLI application, dated 30 January 2014, wherein he reports:

* he fell going down a hill on 11 January 2013
* magnetic resonance imaging (MRI) was performed
* he tore his ACL
* he had a total knee replacement on 25 November 2013

6.  He provides medical documentation which shows he had a follow-up examination of his right knee replacement on 3 December 2013.  His physician reported "he is doing well" with the impression "Localized primary osteoarthrosis of the knee." 

7.  Part B (Medical Professional's Statement) of his TSGLI application, dated 
30 January 2014, shows the attending physicians stated the applicant could not perform bathing, maintaining continence, dressing, eating, toileting or transferring independently during the period 25 November 2013 to 30 December 2014.

8.  On 11 February 2014, the Special Compensations Branch (TSGLI) at the U.S. Army Human Resources Command, Fort Knox, KY denied his claim for TSGLI because he did not meet eligibility requirements.  The letter stated his claim could not be processed because his claimed loss is not a direct result of a qualifying traumatic event.  The TSGLI procedures guide states:

	a.  a traumatic event is 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 the body.

	b. the event must involve a physical impact upon an individual.  Some examples would include:  an airplane crash, a fall in the bathtub, or a brick that falls and causes a sudden blow to the head.  It would not include an injury that is induced by the stress or strain of the normal work effort that is employed by an individual, such as straining one's back from lifting a ladder.  

9.  An official from the TSGLI Office indicated:

* the applicant's TSGLI claims (including an appeal) were denied
* the claimed event was not a qualifying event  

10.  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 May 11, 2005, established the TSGLI program.  U.S. Army 
Combat-Related Special Compensation (CRSC) 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.  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 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 OIF and Operation Enduring Freedom (OEF) or under orders in a Combat Zone Tax Exclusion (CZTE) 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.  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 application of external force or violence (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:

	a.  total and permanent loss of sight in one or both eyes;

	b.  loss of hand or foot by severance at or above the wrist or ankle; 

	c.  total and permanent loss of hearing in one or both ears;

	d.  loss of speech;

	e.  loss of thumb and index finger of the same hand by severance at or above the metacarpophalandeal joints;

	f.  quadriplegia, paraplegia or hemiplegia;
	g.  3rd degree or worse burns covering 30% of body or 30% of the face;

	h.  coma or TBI; or

	i.  other traumatic injuries resulting in the inability to carry out 2 of the 6 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
(15 days or more in the case of TBIs).  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.  

DISCUSSION AND CONCLUSIONS:

1.  Evidence shows the applicant fell in January 2013 and he underwent a total right knee replacement on 25 November 2013. 

2.  The circumstances surrounding his injury do not meet the criteria of a traumatic event.

3.  Additionally, the applicant provided a TSGLI application in which his attending physician stated he was unable to perform 6 ADLs during the period 25 November 2013 to 30 December 2014.  However, no substantiating documentation was attached.  

4.  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.  

5.  He has not provided the required medical documentation for ADL loss, and he has not provided sufficient documentation supporting his contention that he is entitled to TSGLI benefits.

6.  Regrettably, based on the foregoing, there is an insufficient evidentiary basis for granting 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)                                         AR20140003976





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ABCMR Record of Proceedings (cont)                                         AR20140003976



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