IN THE CASE OF:  	  

		BOARD DATE:  11 December 2014	  

		DOCKET NUMBER:  AR20140008087


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 approval of his previously denied Traumatic Servicemembers’ Group Life Insurance (TSGLI) claim.

2.  The applicant states:

   a.  the U.S. Army Human Resources Command (HRC) approved 30 of his 60 day request for TSGLI benefits for an injury he sustained on 24 May 2011;
   
   b.  a medical professional certified his loss of two or more of activities of daily living (ADL) for more than 60 days;
   
   c.  a physical therapist confirmed his bathing and dressing ADLs, for which he required assistance to perform for more than 60 days; and
   
   d.  he met the basic eligibility requirements, paid premiums for TSGLI insurance coverage, and therefore requests a reversal of the decision to deny him the total 60 day TSGLI coverage to authorize payment for an additional 30 days.

3.  The applicant provides:

* Western Law Group Letter
* RHC Letters (2)
* Womack Army Medical Letter
* TSGLI ADL Worksheet
* Standard Form 600 (Chronological Record of Medical Care)
* SGLV Form 8600 (Servicemembers' Group Life Insurance TSGLI) (15 pages)

COUNSEL'S REQUEST, STATEMENT AND EVIDENCE:

1.  Counsel requests reversal of the decision to deny the applicant TSGLI benefits for the full 60 days he is entitled to.

2.  Counsel states:

   a.  the applicant met the following basic eligibility requirements and remains eligible for TSGLI:
   
* was an active duty service member on the date he sustained a traumatic injury
* suffered a loss that was a direct result of a traumatic event
* survived at least seven full days from the traumatic event
* suffered a loss covered under the law within 2 years of the traumatic event and covered under the policy

b.  the applicant sustained a complete rupture of his left quadriceps
tendon which required corrective surgery and from which he continues to struggle with recovery with increased back pain and left knee issues;

	c.  the applicant's post-surgery recovery included his need for daily assistance with ADL's in dressing and bathing for more than 60 days as confirmed by his medical professional in a statement dated 12 November 2012, his physical therapist, and as evidenced on initial his TSGLI Worksheet dated 3 June 2011; and

	d.  the applicant paid premiums for TSGLI insurance coverage and is entitled to the benefits he earned.

3.  Counsel provides no additional documents.

CONSIDERATION OF EVIDENCE:

1.  The applicant's military record shows after having prior enlisted service in the Army National Guard, he was commissioned a second lieutenant (2LT/O-1) in the U.S. Army Reserve (USAR) on 1 April 1985.  He continuously served in the USAR without a break in service and is currently serving on active duty, in the rank of colonel (COL/O-6), as a member of the USAR.
2.  His official military personnel file (OMPF) is void and he does not provide any medical documents prepared at the time he sustained a traumatic injury.

3.  A TSGLI Summary shows:

   a.  while exiting a treadmill on 24 May 2011, the applicant sustained a left quadriceps tendon rupture that was repaired on 26 May 2011;
   
   b.  at the time of his discharge, he was weight bearing at times and noted to be doing well with crutches;
   
   c.  a post-operation note indicated the applicant was doing well and did not need a profile two weeks after his injury;
   
   d.  at 30 days post-injury, a physical therapist noted the applicant needed assistance with bathing and no other ADL impairments were indicated;
   
   e.  subsequent notes showed steady progress in rehabilitation;
   
   f.  the applicant did not meet the TSGLI standards for loss of ADLs and as a result his request for TSGLI coverage was denied on 20 December 2012 and 9 September 2013 (reconsideration); and
   
   g.  a third appeal dated 18 December 2013 included a letter from the applicant's physical therapist wherein the therapist amended her original note dated 3 June 2011 on 5 November 2012 to include a second ADL of dressing at the request of the applicant and his lawyer because the applicant's prior request for TSGLI coverage was denied.  The therapist states as for the ADL noting that “pt needs assistance with bathing” on the additional re-evaluations, that section of the note was forwarded into each new note and does not necessarily reflect the accurate status of the patient at that time.
   
4.  The TSGLI Summary also shows that based on conflicting information in the applicant's medical documents, largely because treatment records were amended over a year after treatment at his and/or his lawyer's request, and all other pertinent information in the applicant's case, it was determined it was possible the loss of ADL for bathing and dressing could have been present for 30 days.  However, the physical therapist notes did not support a loss exceeding 30 days and the benefit of the doubt was given the applicant to recommend approval of 30 days ADL loss of bathing and dressing.


5.  On 25 February 2014, the Chief, Army Personnel Records Division, HRC, notified the applicant his claim had been certified and sent for final disposition with a recommendation of approval for ADL loss of 30 days in the amount of $25,000.00.  His claim of 60 days loss of ADL for bathing and dressing was denied and he was advised to appeal to this Board for any additional relief sought.

6.  The applicant provides a Standard Form 600 from the Womack Army Medical Center, Physical Therapy Clinic, dated 3 June 2011.  It includes a note from the physical therapist dated 5 November 2012 which indicates the applicant needed assistance to help bathing and dressing his lower extremities; however the final disposition shows he was released without limitations.

7.  The applicant also provides a statement from a Womack Army Medical Center physical therapist dated 16 December 2013.  In it the therapist indicates her original note of 3 June 2011 only had one ADL of bathing and that she only amended this note on 5 November 2012 after the applicant contacted her to request the ADL of dressing be added since his TSGLI had been denied.

8.  The applicant provides a TSGLI ADL Worksheet, completed by the physical therapist dated 16 December 2013.  It shows she confirmed the applicant maintained a loss of ADL of bathing and dressing through the end of July 2011.

9.  Part A (Member's Claim Information and Authorization) of SGLV Form 8600 (Application for TSGLI Benefits), dated 1 November 2012, shows:

"On 24 May 2011, in Pinehurst, NC, I was conducting physical training at the gym.  After I finishing running on the treadmill, I started to exit OFF and noticed I hit the PAUSE button instead of the STOP button on the treadmill so the belt was still moving.  So when I exited the treadmill I fell, I felt severe pain to my left knee.  I felt something pop and their [sic] was immediate swelling to my left knee.  I immediately went to the emergency room next door to the gym."

10.  Part B (Medical Professional's Statement) of the SGLV Form 8600 shows the applicant’s attending physician confirmed the applicant's statements that he needed assistance dressing and bathing on 3 June 2012 [sic].  The physician also indicated that patient notes dated 24 June, 23 August, as well as 20 September 2011, documents the service member needed assistance with bathing.

11.  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 and $100,000 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 taken out each month to cover the cost of the TSGLI policy.  Soldiers paying for SGLI coverage cannot decline TSGLI--it is a package.  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.

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 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 percent of body or 30 percent of the face;

	h.  coma or traumatic brain injury; or

	i.  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 
(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 medical 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.  The Soldier must suffer a scheduled loss within 2 years of the traumatic injury.

13.  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 evidence provided by the applicant was carefully considered.  The applicant and his counsel's disagreement with the TSGLI responses are noted; however, the available evidence failed to show the applicant sustained a loss of two ADL's for more than 30 days to authorize him additional TSGLI benefits.  

2.  The evidence of record was void any medical documents to corroborate the applicant's claim as required by the program.  The physical therapist statement he provided shows this medical professional originally noted that on 3 June 2011 the applicant only had a loss of the bathing.  This statement also confirms that nearly 18 months after the applicant's traumatic injury on 5 November 2012 the physical therapist amended her original note only at the request of the applicant because his TSGLI claim(s) were denied, not because the ADL loss was substantiated by appropriate documentation such as Occupational/Physical Therapy Reports, Patient Discharge Summaries, or other pertinent medical documents.

3.  The SGLV Form 8600 also confirms the attending physician in this case only noted the applicant needed assistance with dressing and bathing for 30 days (from 24 May – 23 June 2011).  Thereafter, the physician indicated the applicant continued a loss of the bathing ADL through 20 September 2011.  As a result, TSGLI officials recommended approval of the applicant's claim based conflicting information contained in his medical documents, additional pertinent information, and the possibility of his 30 day loss of two ADLs. 
4.  The applicant has failed to submit evidence that shows the record is in error or unjust.  Therefore, the applicant's request should be denied.

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)                                         AR20140008087





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ABCMR Record of Proceedings (cont)                                         AR20140008087



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