BOARD DATE: 23 January 2018 DOCKET NUMBER: AR20160000356 BOARD VOTE: _________ _______ ________ GRANT FULL RELIEF ________ ________ ________ GRANT PARTIAL RELIEF ________ ________ ________ GRANT FORMAL HEARING __x______ ___x_____ _x___ DENY APPLICATION 2 Enclosures 1. Board Determination/Recommendation 2. Evidence and Consideration BOARD DATE: 23 January 2018 DOCKET NUMBER: AR20160000356 BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined 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. BOARD DATE: 23 January 2018 DOCKET NUMBER: AR20160000356 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, in effect, that his Traumatic Service-Member's Group Life Insurance (TSGLI) claim for losses associated with activities of daily living (ADL) be reconsidered. 2. The applicant states: a. His accident occurred on 2 September 2012 and it resulted in the loss of ADLs. b. The loss of ADLs was also the result of a traumatic brain injury (TBI) that was not properly diagnosed until April 2013. c. He received a neuropsychological examination in April 2013 that shows memory loss issues that started with the accident on 2 September 2012. d. The results of the examination proves that he suffered a TBI at the same time that he lost the ability to take care of himself. e. He believes that the examination should prove that he qualifies for TSGLI payment related to TBI loss of ADLs for 15 days or greater. 3. The applicant provides: * U.S. Army Human Resources Command (HRC) letter, undated * self-authored letter, undated * Fort Belvoir Community Hospital Neuropsychological Evaluation, dated 1 April, 3 April and 4 April 2013 CONSIDERATION OF EVIDENCE: 1. The applicant enlisted in the Indiana Army National Guard (INARNG) on 31 March 2000. He completed training as a firefighter. 2. The applicant’s records show that he initially applied for TSGLI benefits on 10 October 2012. In his application, he stated he had a motor vehicle accident on 2 September 2012. He stated that he fractured his kneecap (right), dislocated his big toe, lacerated his right knee, lacerated his spleen, received a puncture wound to his neck, and he had two throat tracheotomies. He stated that he was in an induced coma for 4 days and in the hospital for 11 days. He stated that he also injured his neck muscles between the 3rd and 4th vertebrae. 4. In his TSGLI claim for benefits, the applicant stated that the predominant reason that he was unable to independently perform ADLs was because his right knee was locked into a right hinged knee brace. He stated that due to multiple injuries, he had impaired balance requiring increased assistance for transfers and ADLs. As his fatigue increased assistance was required and he was in a “c” collar which further limited his neck mobility. He had decreased balance resulting in requiring assistance for both shower transfer and toilet transfer. He used a walker for long distance mobility due to mobility issues and fatigue. He stated that his injuries were from an accident which included neck strain, open fracture (right) patella, abdominal trauma, and puncture wounds in his neck. Within the application he stated he was not able to independently perform ADLs of dressing, toileting, and bathing. 5. On 8 February 2013, the applicant was notified that his claim for TSGLI benefits was denied. a. His loss for hospitalization did not meet the TSGLI standard. Under TSGLI, hospitalization is defined as an inpatient hospital stay, which lasts for 15 or more consecutive days in a hospital or series of hospitals accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations. This includes Combat Support Hospitals, Air Force Theater Hospitals and Navy Hospital Ships. b. His claim for inability to perform ADLs due to traumatic injury (other than TBI) was not approved because his loss did not meet the standards for TSGLI. To qualify, a claimant must have been unable to independently perform at least two ADLs for at least 30 consecutive days. The claimant is considered unable to perform an activity independently only if he or she requires at least one of the following, without which they would be incapable of performing the task: * physical assistance (hands-on) * stand-by assistance (within arm’s reach) * verbal Assistance (must be instructed) 6. The applicant was told that his claim for the inability to perform ADLs due to other traumatic injury was not approved because medical documentation does not support his inability to perform ADLs for 30 days. 7. The applicant submitted an appeal to his request for TSGLI benefits on 14 June 2013 and his appeal was temporarily closed until additional requested information was received. It was noted a medical professional had not certified whether the applicant was able to handle his own affairs. 8. On 16 August 2013, the applicant was notified that his request for TSGLI benefits for loss of ADLs was reconsidered and it was again denied. He was informed that the documentation he submitted did not indicate that his injuries rendered him incapable for performing the ADLs of bathing, continence, toileting, or transferring that are covered by TSGLI standards for 15 consecutive days or greater due to TBI, or for 30 consecutive days or greater due to other traumatic injuries. He was told that if the Soldier is able to perform the activity by the use of accommodating equipment/adaptive measures (such as a personal digital assistant, cane, crutches, wheelchair, etc.), then the Soldier is considered able to independently perform the activity. 9. The applicant submitted a second appeal to his request for TSGLI benefits on 20 October 2014. He was told in an undated letter that after reviewing his claim and supporting documentation, his claim for loss of ADLs due to traumatic injury (other than TBI) for the 30-day milestone was approved. He was to receive a payment of $25,000. He was also told that in reference to TBI-related loss of ADLs, his medical record does not mention any possible TBI-related symptoms until 31 October 2012, 60 days after his traumatic event. He was told that his initial TBI evaluation on 5 November 2012 showed a normal mini-mental status exam, and the Occupational Therapy TBI note from 13 November 2012 states he reported independence in his ADLs. Furthermore, on 21 November 2012, the neuropsychologist believed that most of his cognitive difficulties were secondary to his psychological issues, which were not eligible for payment per program guidelines. He was told that his claim does not qualify for payment related to TBI loss of ADL for 15 days or greater. 10. The applicant provides a self-authored, undated letter stating that the neuropsychological evaluation that was provided on 19 November 2012 was found to be invalid and the psychologist stated any memory problems he had were due to PTSD. He states that he would counter that the PTSD was due to TBI and the really, really poor care that he was receiving at the Fort Knox Warrior Training Battalion clinic. He provides as new evidence, a Fort Belvoir Community Hospital Neuropsychological Evaluation, dated 1, 3 and 4 April 2013. This evaluation was previously considered as part of the appeal he submitted on 14 June 2013, which was eventually denied. 11. During the processing of this case an advisory opinion was obtained from the Army Review Boards Agency (ARBA) Senior Medical Advisor who states: a. A DA 2948 (Special Compensation for Assistance with Activities of Daily Living (ACAADL)) from January 2013 appears significantly incongruent with the applicant's medical and physical status at the time of completion. No recommendation was requested on this issue and the disposition of the application is unknown to the reviewer. b. A review of the available documentation found no clear evidence of a medical disability or condition which would medically support loss of 1, 2, or more ADLs at 15 days or more for TBI in the applicant. Award of TSGLI benefits for TBI at 15 days is not recommended. c. A review of the available documentation found no clear evidence of a medical disability or condition which would medically support loss of 1, 2 or more ADLs at 30 days or more for other traumatic injury in the applicant. Award of TSGLI benefits at 30 or more days is not recommended. 12. The ARBA Senior Medical Advisor recommended denial of the applicant's request. 13. A copy of the advisory opinion was provided to the applicant for his information and/or possible rebuttal. He did not respond. REFERENCES: 1. 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. 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 Operation Iraqi Freedom and Operation Enduring Freedom 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. 2. 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 metacarpophalangeal joints; f. quadriplegia, paraplegia or hemiplegia; g. 3rd degree or worse burns covering 30 percent of the body or 30 percent of the face; h. coma or TBI; 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 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: 1. TSGLI is an insurance program that is bundled with the SGLI. An additional $1 has been added to the Soldier's SGLI premium to cover TSGLI. TSGLI helps traumatically injured Soldiers and their families get through times of need with a one-time payment. TSGLI provides valuable financial support to qualifying members and their families, helping them get through the tough financial times after suffering a severe injury. Qualifying members receive a tax-free payment between $25,000 and $100,000 per traumatic event based on the injury. 2. In the applicant's case, his 2 September 2012 motor vehicle injuries are not in question. However, his medical record does not mention any possible TBI-related symptoms from his accident until 31 October 2012, 60 days after his traumatic event. His initial TBI evaluation on 5 November 2012 showed a normal mental status exam, and the Occupational Therapy TBI note from 13 November 2012 stated he reported independence in his ADLs. 3. His records show that his claim for loss of ADLs due to traumatic injury (other than TBI) for the 30-day milestone was approved. Although he provides a Fort Belvoir Community Hospital Neuropsychological Evaluation, dated 1, 3, and 4 April 2013, this evaluation was previously considered as part of the appeal he submitted on 14 June 2013, which was eventually denied. 4. The ARBA Senior Medical Advisor, after a review of the available documentation, found no clear evidence of a medical disability or condition which would medically support loss of 1, 2, or more ADLs at 15 days or more for TBI or at 30 days or more for any other traumatic injury. The Senior Medical Advisor found no basis for paying the applicant's TSGLI claim based on ADL loss. //NOTHING FOLLOWS// ABCMR Record of Proceedings AR20150000953 Enclosure 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS ABCMR Record of Proceedings (cont) AR20160000356 2 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 1 ABCMR Record of Proceedings (cont) AR20160000356 7 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 2