RECORD OF PROCEEDINGS
AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS

IN THE MATTER OF: 			DOCKET NUMBER: BC-2015-04467

 						COUNSEL:  NONE

						HEARING DESIRED:  NOT INDICATED  

APPLICANT REQUESTS THAT:

His Servicemembers’ Group Life Insurance Traumatic Injury Protection (TSGLI) application be approved.    

APPLICANT CONTENDS THAT:

As noted by his physician in the original claim, he was unable to independently perform the activities of daily living (ADL) for the period of 18 November 2013 through 28 January 2014.  During this period, he was unable to be left alone and was unable to physically care for himself.  Even beyond 28 January 2014, he still required stand by assistance to perform most functions such as bathing, dressing, using the bathroom and transferring.  

The applicant’s complete submission, with attachments, is at Exhibit A.

STATEMENT OF FACTS:

The applicant entered the Air Force Reserve on 23 July 2012.

In the applicant’s TSGLI claim dated 18 July 2014, he requested payment of TSGLI for loss of ADL for the period 18 November 2013 to 28 January 2014. He stated that on 18 November 2013 at approximately 0200 hours, he suffered major multiple trauma injuries as a result of an automobile accident.  He was found three hours later by a nearby resident who called an ambulance.  He sustained an open talus fracture dislocation and a left tibia fracture.  He also suffered from a ruptured bladder, left clavicle fracture, left humeral dislocation, and head fractures.  He was hospitalized and was transferred for in-patient rehabilitation for the period of 30 November 2013 through 17 December 2013.   

The applicant provides a letter dated 31 August 2015 from his occupational therapist for loss of ADL (bathe, dress, eat, toilet, transfer, and maintaining continence independently) for 60 days.  The letter stated, in addition to the documentation already presented, the applicant was not allowed to bear weight on his affected extremity for over 60 days.  He also had difficulty bearing weight on his less affected extremity.  Due to this limitation, he could not safely perform basic ADL tasks independently.  He was also unable to gather supplies to perform these basic ADL with assistance due to his inability to bear weight.  This was the reason it was documented he needed stand by assistance.  

The applicant provides an undated letter of support from his brother.  The letter states the applicant was discharged from the hospital on 18 December 2013 and because he required assistance, he stayed with him on a full time basis for two months.  During this time, the applicant was unable to care for himself without assistance.  He assisted him with bathing, transferring, shaving and dressing.  He helped the applicant every morning transfer from the bathroom to the living area because he was unable to safely do it on his own.  

On 12 January 2016, the applicant was honorably discharged for reason of physical disability per Air Force Reserve Order CA-045, dated 29 December 2015.  

Public Law 109-13 established a traumatic injury program designed to provide financial assistance to service members during recovery from a serious traumatic injury (not necessarily as a result of combat).  The insurance (TSGLI) is a rider to the member’s Servicemember’s Group Life Insurance (SGLI) policy.  TSGLI pays a monetary benefit from $25,000 to $100,000 for covered losses that are incurred by the member as a result of a traumatic injury.

The remaining relevant facts pertaining to this application are contained in the memorandum prepared by the Air Force office of primary responsibility (OPR), which is attached at Exhibit C.    

AIR FORCE EVALUATION:

ARPC/DPTT recommends denial.  There are no medical records to support his claim that assistance was a medical necessity for any time period after 2 January 2014.    

On 18 July 2014, the applicant submitted a TSGLI claim for hospitalization and loss of ADL for the period of 18 November 2013 to 28 January 2014.  The applicant was paid for hospitalization and required assistance for 30 days of ADL.  Whenever combined, the payment for hospitalization takes the place of payment for the first 30 days of ADL.  The applicant received payment in the amount of $25,000.  Based on all medical records provided, there was no compelling documentation that loss of independent functioning to the degree he required stand by assistance for dressing, toileting, and bathing persisted up to the 60 day threshold.  The Occupational Therapy notes dated 2 January 2014, confirms he was able to complete basic ADL, but had some difficulty.  Furthermore, as of 2 January 2014, the applicant was fully capable of self-feeding and grooming, and also able to perform the ADL of bathing, dressing, and toileting, although slowly and with difficulty and in some instances requiring assistance of mechanical or ergonomic devices, such as a shower bench and long‐handled sponge.

A complete copy of the ARPC/DPTT evaluation is at Exhibit C.

APPLICANT'S REVIEW OF AIR FORCE EVALUATION:

A copy of the Air Force evaluation was forwarded to the applicant on 13 April 2016 for review and comment within 30 days (Exhibit D).  As of this date, no response has been received by this office.

ADDITIONAL AIR FORCE EVALUATION:

The BCMR IMA Medical Reviewer recommends denial of the applicant’s appeal for approval of the TSGLI claim.  The applicant’s insurance claims and medical records indicate he sustained multiple musculoskeletal injuries on the morning of 18 November 2013 following an automobile accident.  Traumatic injuries sustained from the accident include multiple upper and lower extremities fractures, ruptured bladder and vertebral fractures.  Records indicate he received initial treatment at the University of North Carolina trauma center and was later transferred to inpatient rehabilitation for occupational and physical therapy from on or about 30 November 2013 through 17 December 2013.  The applicant initially submitted a TSGLI claim for the period of 18 November 2013 to 28 January 2014.  Payment for the initial 30 day period was approved due to hospitalization and inability to perform ADL.  The applicant is appealing for approval of an additional 30 days of coverage from 18 December 2013 through 28 January 2014.  

A review of the medical documentation provided includes a statement from his orthopedist dated August 2014 indicating inability to perform ADL.  Multiple ADL were listed to include that the applicant was unable to toilet, transfer or dress independently.  However, an extensive review of his detailed outpatient treatment plans and goals focused on increasing overall functional capacity and endurance. The BCMR IMA Medical Reviewer concludes the occupational therapy notes submitted for the specified period of appeal (approximately five outpatient visits during the period from 18 December 2013 to 28 January 2014) do not support the signed statement submitted by the orthopedist.  While progress notes clearly reveal treatment plans focused on increasing functional capabilities, there is no supporting evidence of a complete inability to perform required ADL independently.  In fact, during the occupational therapy visit dated 28 January 2014, the therapist documented that the “patient asked if he could try push-ups.”  The BCMR IMA Medical Reviewer opines that any notion to accomplish an exercise which requires lifting approximately 60 to 70 percent of one’s body weight is entirely incompatible with a complete inability to perform any reasonable portion of an ADL independently and further undermines the premise of a complete inability to adequately perform ADL independently for the time period under appeal.  The BCMR IMA Medical Reviewer concludes there was no error or injustice in the partial denial of the applicant’s TSGLI claim.  

A complete copy of the BCMR IMA Medical Reviewer’s evaluation is at Exhibit E.   

APPLICANT'S REVIEW OF ADDITIONAL AIR FORCE EVALUATION:

A copy of the BCMR Medical Consultant’s evaluation was forwarded to the applicant on 10 February 2017 for review and comment within 30 days (Exhibit F).  As of this date, no response has been received by this office.

THE BOARD CONCLUDES THAT:

1.  The applicant has exhausted all remedies provided by existing law or regulations.

2.  The application was timely filed.

3.  Insufficient relevant evidence has been presented to demonstrate the existence of an error or injustice.  We took notice of the applicant’s complete submission in judging the merits of the case; however, we agree with the BCMR Medical Consultant and the office of primary responsibility opinion and recommendation and adopt their rationale expressed as the basis for our conclusion the applicant has not sustained his burden of proof that he has been the victim of an error or injustice.  Therefore, in the absence of evidence to the contrary, we find no basis to recommend granting the requested relief.

4.  The applicant’s case is adequately documented and it has not been shown that a personal appearance with or without counsel will materially add to our understanding of the issues involved.  Therefore, the request for a hearing is not favorably considered.

THE BOARD DETERMINES THAT:

The applicant be notified the evidence presented did not demonstrate the existence of material error or injustice; the application was denied without a personal appearance; and the application will only be reconsidered upon the submission of newly discovered relevant evidence not considered with this application.

The following members of the Board considered AFBCMR Docket Number BC-2015-04467 in Executive Session on 3 August 2017 under the provisions of AFI 36-2603:

	 , Panel Chair
	 , Member
	 , Member

The following documentary evidence was considered:

	Exhibit A.  DD Form 149, dated 16 September 2015, w/atchs.
	Exhibit B.  Applicant's Master Personnel Records.
	Exhibit C.  Memorandum, ARPC/DPTT, dated 18 February 2016.
	Exhibit D.  Letter, AFBCMR, dated 13 April 2016.
	Exhibit E.  Memorandum, BCMR IMA Medical Consultant, dated 
  17 January 2017.
	Exhibit F.  Letter, AFBCMR, dated 10 February 2017.  

Pursuant to paragraph 1 of AFI 36-2603 (Title 32 Code of Federal Regulations, Part 865.1), it is certified that a quorum was present at the Board's review and deliberations, and that the foregoing is a true and complete record of the Board's proceedings in the above entitled matter.