RECORD OF PROCEEDINGS AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS IN THE MATTER OF: DOCKET NUMBER: BC-2010-00550 COUNSEL: NONE HEARING DESIRED: NO _________________________________________________________________ APPLICANT REQUESTS THAT: His honorable discharge be changed to a medical discharge. _________________________________________________________________ APPLICANT CONTENDS THAT: There was enough medical and psychological evidence to warrant a medical discharge. In support of his appeal, the applicant provides extract copies from his medical records, a letter to his Congressman, his Department of Veterans Affairs (DVA) disability rating decisions and an article on Post Traumatic Stress Disorder (PTSD). The applicant’s complete submission, with attachments, is at Exhibit A. _________________________________________________________________ STATEMENT OF FACTS: The applicant enlisted in the Regular Air Force on 4 January 2001 and was discharged on 3 January 2007 in the grade of staff sergeant due to completion of required active service. He served six years of active military service. The applicant’s medical records reflect he received an evaluation and ongoing treatment for anxiety and panic attacks. The applicant continued in another series of care episodes for anxiety, panic attacks, with agoraphobia and the addition diagnosis of PTSD, from January 2006 through July 2006. The evaluating mental health providers rendered the applicant non- worldwide qualified. On 17 July 2009, a Memorandum from the Office of the Under Secretary of Defense directed the Physical Disability Board of Review (PDBR) in reviewing prior disability ratings to disregard any Military Department guidelines that were inconsistent with the Veterans Administration Schedule for Rating Disabilities (VASRD). While reliance on section 4.130, rather than section 4.129, was arguably consistent with the VASRD, the PDBR has concluded that equity favors giving applicants the benefit of section 4.129. Consultations with the BCMRs indicate recognition of the desirability of consistency among the BCMRs and PDBR in adjudicating these cases. The VASRD has two applicable sections. Section 4.129 calls for a temporary rating of not less than 50 percent, followed by an examination within 6 months of discharge for an individually assessed rating. Section 4.130 provides standards for a mental health examination to assess the degree of impairment for the member’s continuing rating. Historically, the practice of Military Department disability agencies was to complete the comprehensive section 4.130 mental health assessment prior to the member’s separation, and therefore to dispense with 4.129. Therefore, as a matter of policy, the PDBR and all three BCMRs will apply VASRD section 4.129 to PTSD unfitting conditions for applicants discharged after 11 September 2001, and in such cases, where a grant of relief is appropriate, assign a disability rating of not less than 50 percent for PTSD unfitting conditions for an initial period of six month following separation, with subsequent fitness and PTSD ratings based on the applicable evidence. The remaining facts pertaining to this application, extracted from the applicant's military records, are contained in the letter prepared by BCMR Medical Consultant (Exhibit C). _________________________________________________________________ AIR FORCE EVALUATION: The BCMR Medical Consultant recommends approval. The Medical Consultant states the applicant was diagnosed with a medical condition that should have triggered a Medical Evaluation Board (MEB); or as a minimum, a review in-lieu of MEB, if his health care providers believed the applicant viable for retention and follow-up evaluation in one year. The fact that the applicant was lost to follow-up, does not remove the responsibility of the Military Department to execute proper administrative options available. The facts of the record shows the applicant to be disqualified for service, at least for PTSD, with the presumption that had he undergone a MEB and his case was timely referred to a Physical Evaluation Board (PEB), he would have been found unfit and placed on the TDRL with a 50 percent disability rating for a period of six months; at which time a re-evaluation would have been conducted to determine the final rating. The Medical Consultant states the record should be amended to reflect the applicant was placed on the Temporary Disability Retired List (TDRL) with a 50 percent disability rating for PTSD, effective 3 January 2007, followed by a timely reevaluation by a psychiatrist, upon which a determination of the applicant’s fitness to serve and the disability rating would be determined by the Informal Physical Evaluation Board (IPEB). The complete Medical Consultant evaluation is at Exhibit C. _________________________________________________________________ APPLICANT'S REVIEW OF AIR FORCE EVALUATION: On 14 October 2010, a copy of the Air Force evaluation was sent to the applicant for review and comment. As of this date, this office has not received a response (Exhibit D). _________________________________________________________________ THE BOARD CONCLUDES THAT: 1. The applicant has exhausted all remedies provided by existing law or regulations. 2. The application was timely filed. 3. Sufficient relevant evidence has been presented to demonstrate the existence of error or injustice warranting relief. We note the requirements set forth in the policy memorandum issued by the Office of the Under Secretary of Defense regarding disability ratings for PTSD and the comments provided by the BCMR Medical Consultant. We agree with the opinion and recommendation of the BCMR Medical Consultant and adopt his rationale as the basis for our conclusion that the applicant has been the victim of an error or injustice. Therefore, we recommend the applicant’s records be corrected as indicated below. _________________________________________________________________ THE BOARD RECOMMENDS THAT: The pertinent military records of the Department of the Air Force relating to APPLICANT, be corrected to show that: a. On 3 January 2007, the applicant was found unfit to perform the duties of his office, rank, grade, or rating by reason of physical disability, incurred while he was entitled to receive basic pay; that the diagnosis in his case was Post Traumatic Stress Disorder, a condition which is rated at a compensable percentage of 50%; that the degree of impairment was permanent; that the disability was not due to intentional misconduct or willful neglect; that the disability was not incurred during a period of unauthorized absence; and that the disability was received in the line of duty as a direct result of armed conflict or caused by an instrumentality of war. b. On 4 January 2007, his name was placed on the Temporary Disability Retired List (TDRL), with a compensable disability rating of 50 percent. c. He be immediately reevaluated by a psychiatrist, following which a determination of his fitness to serve and final disposition be made by the Informal Physical Evaluation Board (IPEB). _________________________________________________________________ The following members of the Board considered Docket Number BC- 2010-00550 in Executive Session on 7 December 2010, under the provisions of AFI 36-2603: All members voted to correct the record, as recommended. The following documentary evidence was considered: Exhibit A. DD Form 149, dated 3 Feb 10, w/atchs. Exhibit B. Applicant's Master Personnel Records. Exhibit C. Letter, Medical Consultant, dated 11 Oct 10. Exhibit D. Letter, SAF/MRBR, dated 14 Oct 10.