ARMY BOARD FOR CORRECTION OF MILITARY RECORDS

RECORD OF PROCEEDINGS


	 

	BOARD DATE:  20 August 2019

	DOCKET NUMBER:  AR20180013931


APPLICANT REQUESTS: in effect, correction to his Standard Form 88 (Report of 
Medical Examination), dated on or about 5 October 1983 to show he incurred trauma to 
his right eye as a result of an injury he incurred in the line of duty on July 1982.  

APPLICANT'S SUPPORTING DOCUMENTS CONSIDERED BY THE BOARD: 

*	DD Form 149 (Application for Correction of Military Record)
*	Standard Form (SF) 88 (Report of Medical Examination) page 2, dated 
28 November 1973
*	SF Form 93 (Report of Medical History) page 2
*	Department of Veterans Affairs (VA) Rating Decision, dated 13 October 1983
*	excerpt of Military Service Treatment Records 8 pages 
*	SF 88 page 2, Separation Physical 

FACTS:

1.  The applicant did not file within the 3 year time frame provided in Title 10, United 
States Code (USC), section 1552 (b); however, the Army Board for Correction of 
Military Records conducted a substantive review of this case and determined it is in the 
interest of justice to excuse the applicant's failure to timely file. 

2.  The applicant states his medical records should be corrected to show he incurred an 
injury to his right eye in July 1982.  The lack of medical evidence within his military 
medical exit exam has caused him undue hardship because the Department of 
Veterans Affairs (VA) does not recognize his injury as service connected.  This can be 
corrected by the Board by correcting his medical records.  Without a correction to his 
medical records, he feels he has unjustly been denied VA benefits.  He injured his right 
eye when metal shavings entered his eye during a motor pool incident that occurred 
when he was stationed in West Germany.  He states, in effect, the (physical) examiner 
dismissed his new eye trauma (due to a scar that was considered a preexisting medical 
condition) when the medical examiner conducted his (separation physical) exam and 
prepared the medical examination report.  He states the lack of due diligence in 
documenting his 1982 eye injury during his final physical exam is an injustice that 
warrants correction by the Board.

3.  With prior service, the applicant enlisted in the Regular Army on 6 June 1979 for a 
4 year period of service.  His medical service treatment records are not available to the 
Board to review from the National Archives.  However, the applicant provided sufficient 
evidence though in poor quality for the Board to review and render a decision under the 
provisions of Title 10, UCS, section 1552 and Army Regulation 15-185 (Army Board for 
Correction of Military Records).

4.  On 5 October 1983 the applicant was released from active duty upon the completion 
of his enlistment contract.  He received an honorable discharge and was issued a 
DD Form 214 (Certificate of Release or Discharge from Active Duty) showing he was 
discharged under the provisions of Army Regulation 635-200 (Personnel Separations – 
Enlisted Personnel), chapter 4.  

5.  The applicant provided the following evidence.

     a.  Page 2 of SF 88 shows he was qualified for enlistment/reenlistment on 
16 November 1973.  Item 73 (Notes) contains this entry, "Eye – OD [optical density] – 
Corneal scarring."  This form contains a drawing showing approximately where the 
corneal scarring is located.  His eyes were correctable to 20/70.  On 28 November 1973 
a medical doctor reviewed his physical examination documents stating there were no 
disqualifying diseases or communicable diseases were noted.  The doctor signed the 
form with his signature attesting to the applicant’s physical profile rating of "2" for his 
eyes.  The remainder of the physical and psychological categories were rated "1" with 
no profile limitations.  

     b.  Page 2 of SF 93 shows in item 25 (Physician’s Notes, et. al.) an entry showing a 
history of having a cactus needle in his eye that scarred his cornea with optical density 
when he was a small child.  The physician said to see the eye diagram on the SF 88.  

     c.  A SF 600, dated 1 July 1982, shows at a medical clinic in Mannheim, West 
Germany the applicant sought medical treatment for his right eye.  He said he had eye 
irritation from a foreign object.  During an eye examination, the treating physician stated 
a small abrasion was visible in the right eye and he should follow up with the eye clinic 
the next day.     

     d.  A SF 600, dated 22 July 1992, shows he sought follow-up treatment for an eye 
injury at the optometry clinic.  The medical provider, a doctor of optometry, drew a 
diagram showing the applicant’s old corneal scar and the location in the lower left 
quadrant of his eye of his new injury, a very faint residual hemosiderin deposit.  He was 
advised to follow-up in 90 days if the deposit was not gone. 

     e.  A SF 600, dated 27 January 1983, show he was seen at a military optometry 
clinic because he failed a Texas driver license eye examination.  His vision screen was 
20/200 and 20/20 with a prescription his eyes were correctable to 20/80 and 20/20.  
There is no annotation on the form showing he had corneal scar(s). 

     f.  On 21 July 1983, a medical document shows he was seen at the optometry clinic 
and was referred to the ophthalmology clinic.   The form states he has corneal scarring 
and that his eyesight is correctable to 20/80 and 20/20.  The optometry clinic request 
the ophthalmology clinic evaluate him for a physical profile.  There are note showing he 
injured his eye and had foreign objects removed from his eye in August 1982.  It further 
states he also had a foreign object removed from his eye at age 4 which is now shown 
as corneal scarring or staining.  

     g.  Page 2 of SF 88 shows in item 74 (Summary of Defects and Diagnoses) an entry 
stating the applicant has corneal scar within in right eye and his vision is improved with 
visual acuity (glasses).  The medical doctor stated the applicant was medically qualified 
for separation in accordance with Army Regulation 40-501 (Standards of Medical 
Fitness).  At the time of separation the applicant had no limiting profiles and was rated 
all “1s” across the six profiling standards including his eye sight. 

     h.  On 13 October 1983 the VA provided the applicant with a rating decision that 
contains, in effect, a statement showing he does claim a right eye injury which was 
noted on his entrance physical examination as corneal scarring.  His visual acuity was 
20/200 with correction to 20/70.  The VA determined there was no aggravation to his 
right eye or injury while in service.  While in service he was diagnosed with hyperopic 
astigmatic eye and simple hyperopia of his left eye.  The applicant’s corneal abrasions 
are shown to have existed prior to enlistment with no aggravation while in service.  The 
rest of the medical note is not decipherable.  

6.  In the processing of this case, a medical advisory was obtained from the Army 
Review Boards Agency senior medical advisor, a medical doctor.  On 1 July 2019, the 
doctor rendered an opinion as required by law.  He summarized the applicant’s medical 
evidence noting he entered the service with a right eye corneal scar and then he injured 
his right eye when possible foreign fragments entered it on or about 1 July 1982.  
Following the injury there are two examinations showing his eye had healed.  The 
medical doctor states, "Resolved injuries such as this one do not entitle service 
members to disability ratings by the Army."  A copy of the complete medical advisory 
was provided to the Board for their review and consideration.

7.  On or about 3 July 2019, the applicant was sent the medical advisory opinion for his 
review and rebuttal.  The applicant responded by stating, "In his mind, as the facts will 
prove the record indeed shows to be in error, thus unjust.  It is my contention that due 
diligence in this matter was overlooked, or ignored."  In summary, the applicant appears 
to believe the Case Management Division rendered a board decision on his application 
and expresses himself by stating, "Case Management Division was tasked to determine 
one simple record of fact; to show whether a service related injury occurred, based on 
available documents at their disposal."  He attempted to provide two new pieces of 
information to support his application.  However, they were not received nor attached to 
his rebuttal statement.  He said two senior noncommissioned officers provided witness 
statements attesting to his 1982 injury.  The witness statements were apparently dated 
in 2007 and in 2017.  Near the end of his rebuttal statement he states, in effect, that his 
medical record recorded his preexisting corneal scarring of his right eye and his injury 
that occurred in 1982.  He concludes by stating the medical examiner who prepared his 
separation physical committed an error when he did not enter the eye scarring incident 
of 1982 as a diagnosis on his separation physical.  He states because of this error he 
has suffered a hardship and subsequently been denied benefits from the VA.  

BOARD DISCUSSION:

1.  The Board carefully considered the applicant’s request, supporting documents, 
evidence in the records and a medical advisory opinion.  The Board considered the 
applicant’s statement, his record of service, available medical records and the date of 
his separation.  The Board considered the assessment of his corneal scar by in-service 
medical professionals, the treatment for an object in his eye, the subsequent 
documentation of it being healed, his separation physical and the review and 
conclusions of the medical advising official.  The Board concurred with the conclusion of 
the medical advisor and determined there was insufficient evidence to show that the 
applicant sustained a traumatic injury to his eye during his period of service.

2.  After reviewing the application and all supporting documents, the Board found that 
relief was not warranted.


BOARD VOTE:

Mbr 1	Mbr 2	Mbr 3

:	:	:	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 the overall merits of this case are insufficient 
as a basis for correction of the records of the individual concerned.
  


	  
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.


ADMINISTRATIVE NOTE(S):

Not Applicable



REFERENCES:

1.  Title 10, USC, section 1552(b), provides that applications for correction of military 
records must be filed within 3 years after discovery of the alleged error or injustice.  This 
provision of law also allows the Army Board for Correction of Military Records (ABCMR) 
to excuse an applicant's failure to timely file within the three-year statute of limitations if 
the ABCMR determines it would be in the interest of justice to do so.

2.  Army Regulation 40-66 (Medical Record and Quality Assurance Administration) sets 
policies and procedures for the preparation and use of Army medical records and the 
administration of the Army’s Quality Assurance Program.  The purpose of the medical 
record is to provide a complete medical history for patient care, medicolegal support, 
and research and education.  A medical record also provides a means of 
communication where necessary to fulfill other Army requirements. 

     a.  The official custodian of the medical or dental records is the medical treatment 
facility commander.  The purpose of the health record is to ensure health care providers 
has a concise but complete medical history of everyone on active duty or in the Reserve 
Component. 

     b.  The unit commander will ensure that health records are always available to Army 
Medical Department (AMEDD) personnel.  AMEDD officers will use the health record for 
recording diagnosis and treatment.  They will also use it for conversations and 
improvement of the health of the individual concerned.  In doing so, AMEDD officers will 
see that all needed information is promptly entered into the military health record in their 
custody.  If any such information is omitted, the officers will take the needed action to 
have it included.  

     c.  Health care providers will record promptly and correctly all patient observations, 
treatments, and care.  

     d.  Army medical records are the property of the United States Government.  
Corrections to entries will be done by drawing a single line through the information that 
is wrong with the information remaining readable.  The new information is then added, 
dated and signed by the person making the correction.  Deletion, obliteration, or 
destruction of medical record information is not authorized.  

     e.  Amendments to medical records will be amended as per paragraph 2-10 of Army 
Regulation 340-21 (The Army Privacy Program).

     f.  An outpatient treatment record will be prepared for each patient treated as an 
outpatient at a United States medical and dental treatment facility The Standard Form 
88 (Report of Medical Examination) and Standard Form 93 (Report of Medical History) 
will be filed in the medical treatment record as a permanent document.  Standard 
Form 600 (Health Record) is used to record an encounter with AMEDD providers. 

ABCMR Record of Proceedings (cont)	 AR20180013931

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