BOARD DATE: 17 April 2020 DOCKET NUMBER: AR20180014448 APPLICANT REQUESTS: in effect, referral to the Physical Disability Evaluation System (PDES) for determination of physical disability. APPLICANT'S SUPPORTING DOCUMENTS CONSIDERED BY THE BOARD: * DD Form 149 (Application for Correction of Military Record) * DD Form 214 (Certificate of Release or Discharge from Active Duty), ending 19 May 2004 * Medical document indicated on DD Form 149 were not included FACTS: 1. The applicant did not file within the three year time frame provided in Title 10, United States Code, section 1552(b); however, the ABCMR conducted a subs tantive 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 that he was repeatedly injured due to combat operations (Convoy Security) in Iraq. He was discharged/separated from the military without having his injuries evaluated by a Medical Evaluation Board (MEB) or a Physical Evaluation Board (PEB). The failure to follow regulations and procedures has limited his access to benefits. 3. The applicant enlisted in the New Jersey Army National Guard (NJARNG) on 26 January 2001. 4. He was ordered to active duty in support of Operation Enduring Freedom/Iraqi Freedom, for the period 7 February 2003 to 19 May 2004. 5. The applicant did not provide his medical records; however, his military records contain a DA Form 2173 (Statement of Medical Examination and Duty Status) which shows that while assigned to Iraq he was involved in a vehicle accident, in late February 2003, injuring his back and shoulder. This form also shows that he inhaled sulfur dioxide in July 2003. The applicant received outpatient treatment at a military hospital in Mosul Iraq and his injuries were considered temporary, not likely to result in a claim against the government for future medical care, and incurred in the line of duty. 6. The applicant's record contains a DD Form 214 (Certificate of Release or Discharge from Active Duty) showing he was honorably released from active duty for completion of required active service on 19 May 2004. 7. The applicant was discharged from the NJARNG on 15 August 2005 by reason of medical unfitness for retention. His record is void of the circumstances of his discharge. 8. His Official Military Personnel File (OMPF) contains an application for Traumatic Servicemen Group Life Insurance, which includes the applicant's Department of Veterans Affairs Rating Decision, dated 9 November 2013. This document shows the applicant received service connected disability ratings for several injuries/illnesses to include Traumatic Brain Injury (TBI). 9. The Army Review Board Agency (ARBA) Medical Advisor reviewed the supporting documents and the applicant's records in iPERMS, the Armed Forces Health Longitudinal Technology Application (AHLTA), Health Artifacts Image Management Solutions (HAIMS) and the VA's Joint Legacy Viewer (JLV) and made the following findings and recommendations: The applicant enlisted in the New Jersey Army Reserve National Guard (NJARNG) on 26 January 2001. On 7 February 2003 he was ordered to Active Duty in support of Operation Enduring Freedom, and served in Iraq through 19 May 2004. While serving in Iraq in February 2004 the applicant states that he was injured while manning the turret when the military vehicle he was riding in roughly traversed a median in the road resulting in the applicant being slung from side to side. The applicant reported that he injured his lower back and left shoulder as a result of the incident. There is no report of head injury or loss of consciousness at the time of the incident. The applicant was medically evaluated on 4 March 2004 and found to have moderate left paralumbar tenderness with muscle spasm, no neck pain or tenderness, no obvious signs of head injury, and no obvious evidence of trauma of the left shoulder. A plain radiograph of the lumbar spine done at that time reportedly demonstrated no evidence of fracture or dislocation. An informal line of duty (LOD) medical examination determined that the injuries reported by the applicant occurred in the line of duty, and a formal LOD was not required. He was treated conservatively with pain and anti-inflammatory medications, instructed on range of motion exercises, and placed on a temporary profile. On 5 March 2004 the applicant reported improvement in his symptoms. The applicant was able to complete his deployment in Iraq, and was released from Active Duty (REFRAD) on 19 May 2004 and returned to his NJARNG unit. On 15 August 2005, according to the applicant’s NGB Form 22, the applicant was honorably discharged from the NJARNG IAW NGR (AR) 600-200, Paragraph 6- 35I(8) for reason of being medically unfit for retention IAW AR 40-501. However, there are no documents included to establish the exact reason as to why the applicant was deemed to be medically unfit IAW AR 40-501. Based on the clinical notes related to the injuries the applicant sustained while deployed it would not appear that these injuries would rise to the level of causing the applicant to be considered medically unfit. There are no other medical records available for review following the applicant’s return from Iraq. According to JLV the applicant currently has a combined service connected rating of 100% for multiple medical and behavioral health conditions, but again there is no documentation to indicate any of the diagnoses listed on the applicant’s problem list in JLV occurred while the applicant was serving in the Army. Therefore, it is the conclusion of the Agency Medical Advisor, based on the available documentation, that there is no indication for the applicant’s record to be referred to the Disability Evaluation System for consideration for military medical retirement at this time. 10. Under the laws governing the Physical Disability Evaluation System, Soldiers who sustain or aggravate physically-unfitting disabilities must meet several LOD criteria to be eligible to receive retirement and severance pay benefits. The disability must have been incurred or aggravated while the Soldier was entitled to basic pay or was the proximate cause of performing active duty or inactive duty training. 11. The Board should consider all factors in accordance with the published equity, injustice, or clemency determination guidance. BOARD DISCUSSION: After reviewing the application, all supporting documents, and the evidence found within the military record, the Board found that relief was not warranted. The applicant’s contentions, the military record, an advisory opinion, and regulatory guidance were carefully considered. Evidence of record shows the applicant met retention standards during his period of active duty service and separated at his completion of required active service. The record also shows, based on the clinical notes related to the injuries the applicant sustained while deployed, it would not appear that these injuries would rise to the level of causing the applicant to be considered medically unfit. Based upon a preponderance of the evidence to include the recommendation of the advisory official, the Board determined there is insufficient evidence that shows a referral to the Physical Disability Evaluation System (PDES) was warranted during his period of active service. ? 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, United States Code, 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 ABCMR to excuse an applicant's failure to timely file within the 3 year statute of limitations if the Army Board for Correction of Military Records (ABCMR) determines it would be in the interest of justice to do so. 2. Army Regulation 635-40 (Physical Evaluation for Retention, Retirement, or Separation) governs the evaluation of physical fitness of Soldiers who may be unfit to perform their military duties because of physical disability incurred while entitled to basic pay. It states that the mere presence of impairment does not, of itself, justify a finding of unfitness because of physical disability. In each case, it is necessary to compare the nature and degree of physical disability present with the requirements of the duties the Soldier reasonably may be expected to perform because of his or her office, grade, rank, or rating. Under the laws governing the PDES, Soldiers who sustain or aggravate physically-unfitting disabilities must meet several LOD criteria to be eligible to receive retirement and severance pay benefits. The disability must have been incurred or aggravated while the Soldier was entitled to basic pay or was the proximate cause of performing active duty or inactive duty training. 3. Title 10, U.S. Code, chapter 61, provides the Secretaries of the Military Departments with authority to establish service PDES for the purpose of retiring or discharging a member if they find the member unfit to perform military duties because of physical disability. The U.S. Army Physical Disability Agency, under the operational control of the Commander, U.S. Army Human Resources Command (HRC), is responsible for operating the Army's PDES and executes Secretary of Army decision-making authority as directed by Congress in Title 10, U.S. Code, chapter 61, and in accordance with Department of Defense Directive 1332.18 and AR 635-40. The objectives of the system are to: * maintain an effective and fit military organization with maximum use of available manpower * provide benefits for eligible Soldiers whose military service is terminated because of service-connected disability * provide prompt disability processing while ensuring that the rights and interests of the government and the Soldier are protected 4. AR 40-501 (Standards of Medical Fitness) governs medical fitness standards for retention and separation, including retirement. Chapter 7 (Physical Profiling), provides that the basic purpose of the physical profile serial system is to provide an index to the overall functional capacity of an individual and is used to assist the unit commander and personnel officer in their determination of what duty assignments the individual is capable of performing and if reclassification action is warranted. a. Paragraph 7-3 (Physical profile serial system) - Four numerical designations (1-4) are used to reflect different levels of functional capacity in six factors (PULHES): P- physical capacity or stamina, U-upper extremities, L-lower extremities, H-hearing and ears, E-eyes, and S-psychiatric. (1) Numerical designator 1 under all factors indicates that an individual is considered to possess a high level of medical fitness and, consequently, is medically fit for any military assignment. (2) Numerical designators 2 and 3 indicate that an individual has a medical condition or physical defect which requires certain restrictions in assignment within which the individual is physically capable of performing military duty. The individual should receive assignments commensurate with his or her functional capacity. (3) Numerical designator 4 indicates that an individual has one or more medical conditions or physical defects of such severity that performance of military duty must be drastically limited. The numerical designator 4 does not necessarily mean that the individual is unfit because of physical disability as defined in AR 635-40. b. Paragraph 9-12 (Request for PEB evaluation) states that the Reserve Component Soldiers with non-duty related medical conditions who are pending separation for failing to meet the medical retention standards are eligible to request referral to a PEB for a determination of fitness. Because these are cases of RC Soldiers with non-duty related medical conditions, MEBs are not required and cases are not sent through the PEB Liaison Officers at the medical treatment facilities. Once a Soldier requests in writing that his or her case be reviewed by a PEB for a fitness determination, the case will be forwarded to the PEB by the U.S. Army Reserve Command Regional Support Command or the HRC Command Surgeon's office and will include the results of a medical evaluation that provides a clear description of the medical condition(s) that cause the Soldier to not meet medical retention standards. c. Paragraph 10-25 (Not in the Line of Duty (NILOD)) states the Department of Defense Instruction 1332.38 (Physical Disability Evaluation) states that members with non-duty related impairments are eligible to be referred to the PEB solely for a fitness determination, but not a determination of eligibility for disability benefits. Further explanation is available in TAPD-Policy Memorandum #4, Processing Reserve Component Non-Duty Related Cases. This policy memorandum outlines the procedures and requirements for processing boards on Reserve Component Soldiers with non-duty related impairments that are pending separation for medical disqualification. Determination of whether a non-duty case is forwarded to the PEB is at the request of the Soldier. The Soldier will have a completed LOD or memo that notifies him/her of non-duty related findings (NILOD). The Soldier may not challenge the PEB findings in person. d. Paragraph 10-25a(2) states the Military Personnel Office is responsible for notifying the Soldier, in writing, that his/her injury is NILOD and that he/she is pending separation for a medical disqualifying condition. The notification will also advise the Soldier that he/she has the right to prepare a Non-Duty PEB packet for a fitness determination. 5. National Guard Regulation 600-200 (Enlisted Personnel Management) states that Commanders, who suspect that a Soldier may not be medically qualified for retention, will direct the Soldier to report for a complete medical examination per AR 40-501. Commanders who do not recommend retention will request the Soldier’s discharge. When medical condition was incurred in line of duty, the procedures of AR 600-8-4 will apply. Discharge will not be ordered while the case is pending final disposition. 6. On 25 August 2017, the Office of the Undersecretary of Defense for Personnel and Readiness issued clarifying guidance for the Secretary of Defense Directive to DRBs and BCM/NRs when considering requests by Veterans for modification of their discharges due in whole or in part to: mental health conditions, including PTSD; traumatic brain injury; sexual assault; or sexual harassment. Boards are to give liberal consideration to Veterans petitioning for discharge relief when the application for relief is based in whole or in part on those conditions or experiences. The guidance further describes evidence sources and criteria and requires Boards to consider the conditions or experiences presented in evidence as potential mitigation for misconduct that led to the discharge. 7. On 25 July 2018, the Under Secretary of Defense for Personnel and Readiness issued guidance to Military Discharge Review Boards and Boards for Correction of Military/Naval Records (BCM/NRs) regarding equity, injustice, or clemency determinations. Clemency generally refers to relief specifically granted from a criminal sentence. BCM/NRs may grant clemency regardless of the type of court-martial. However, the guidance applies to more than clemency from a sentencing in a court- martial; it also applies to other corrections, including changes in a discharge, which may be warranted based on equity or relief from injustice. This guidance does not mandate relief, but rather provides standards and principles to guide Boards in application of their equitable relief authority. In determining whether to grant relief on the basis of equity, injustice, or clemency grounds, BCM/NRs shall consider the prospect for rehabilitation, external evidence, sworn testimony, policy changes, relative severity of misconduct, mental and behavioral health conditions, official governmental acknowledgement that a relevant error or injustice was committed, and uniformity of punishment. Changes to the narrative reason for discharge and/or an upgraded character of service granted solely on equity, injustice, or clemency grounds normally should not result in separation pay, retroactive promotions, and payment of past medical expenses or similar benefits that might have been received if the original discharge had been for the revised reason or had the upgraded service characterization. //NOTHING FOLLOWS// ABCMR Record of Proceedings (cont) AR20180014448 3 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1