IN THE CASE OF: BOARD DATE: 17 January 2024 DOCKET NUMBER: AR20230005881 APPLICANT REQUESTS: in effect, correction of his Army National Guard (ARNG) records to show he was discharged from the ARNG due to “disability” vice being medically unfit for retention. APPLICANT'S SUPPORTING DOCUMENT(S) CONSIDERED BY THE BOARD: * DD Form 149 (Application for Correction of Military Record) * DD For 214 (Certificate of Release or Discharge from Active Duty) * 2020 Honorable Discharge Order and Certificate * Department of Veterans Affairs Rating Decision, September 2022 * Notice of Disagreement (VA) * Statements in Support of Claim FACTS: 1. The applicant states he had order to travel for military training to St. Croix on November I9, 2012 to November 21, 2012. During his return to his house on November 21, 2012, he suffered a car accident with several damage and consequences. He received emergency services and hospitalization. The government and local protocol were continued government insurance to cover his damage and medical follow-up. His family followed the instructions, and he was excused to his next training date on November 26, 2012. However, his family never received guidance of active an LOD (line of duty) to receive his military benefits and follow-up. He never received guidance about this process. Now, the Veteran Benefits Administration is denying his claim for service connected because during his training/orders his unit never completed the LOD. His unit provided him support to complete his task until he was unable to continue and request social security benefits. He needed evidence of a defense authority to clarify this error. He attached evidence of his orders, and a co-worker’s testimony of their visual observation of his accident after completing that day of training. 2. Review of the applicant’s service records shows: a. He enlisted in the Puerto Rico Army National Guard (PRARNG) on 7 April 2009. He entered active duty or training on 8 July 2009 and completed training for award of military occupational specialty (MOS) 88L, Watercraft Engineer. b. He was honorably released from ADT on 25 November 2009 to the control of the ARNG. His DD Form 214 shows he completed 4 months and 18 days of active service. c. On 12 November 2012, he was ordered to State Full Time National Guard Duty from 19 to what appears to be 26 November 2012. d. The applicant’s NCO Evaluation Reports during June 2016 to June 2019 show substandard duty performance and multiple poor ratings of “Did Not Meet Standards” with comments such as: * failed Army Physical Fitness Test twice * displayed questionable leadership ability; failed to set the example for peers and subordinates * places more importance on and effort into personal phone calls than his duties * presents sharp military appearance but needs to realize importance of subtlety * the last position of Soldiers that I rate on this grade * set one of the lowest examples of leadership in the Unit and was generally distrusted by seniors, peers, and subordinates e. On 30 October 2018, the applicant’s commander notified the applicant of the initiation of action to separate him from the PRARNG in accordance with Army Regulation (AR) 135-178 (Enlisted Administrative Separations), paragraph 14- 1k. The reason for the proposed action is due to his medical condition, which does not allow him to perform military duties required for his MOS. f. The applicant acknowledged receipt and made an election requesting referral to a non-duty related (NDR) physical evaluation board (PEB) for the purpose of fitness determination, per the following references: Army Regulation (AR) 635-40, Physical Evaluation for Retention, Retirement, or Separation, dated 8 February 2006; DOD Directive 1332.18; DOD Instructions 1332.38; and Policy/Guidance Memorandum #4; Processing Reserve Component (RC) Nonduty­ Related (NOR) Cases. He acknowledged the following: (1) He has been fully informed and understand that he is entitled to the same consideration and processing as any other Soldier of the Army Separated for Physical Disability. He understood this includes the consideration of his case by a Physical Evaluation Board. He also understood the Veterans Administration (VA) will determine entitlement to VA benefits. (2) He understood that if found unfit by the PEB, he would be separated by reason of medical disqualification. He also understood that he would receive a discharge in keeping with the character of my service. as decided by the office designated to affect his separation. g. On 13 August 2019, a formal PEB convened and found the applicant unfit due to Encephalomalacia. This is a NDR case. Soldier was diagnosed with condition after an accident with no date of occurrence provided. The condition is characterized by a local softening of the brain tissue that resulted from injury and inflammation. On 30 October 2018, the PRARNG indicated this condition does not meet medical fitness standards. This condition is not compensable because the PEB's review of available military and civilian medical records did not reveal any evidence that the condition was either incurred or aggravated while on active duty. This Soldier is unfit because DA Form 3349, Physical profile limitations associated with this condition prevents him from performing Section 4 functional activities 24f; live and function, without restrictions in any geographic or climatic area without worsening condition. Therefore, the Soldier is unfit. h. The PEB found the applicant physically unfit and that his disposition be referred for case disposition under RC (Reserve Component) regulations. i. The applicant did not concur and provided a written appeal. j. On 14 January 2020, the U.S. Army Physical Disability Agency (USAPDA) responded to the applicant’s rebuttal and informed the applicant thru The Adjutant General, that the USAPDA has noted his disagreement with the findings of the PEB and has reviewed his entire case. The Agency's conclusion is that his case was properly adjudicated by the PEB, which correctly applied the rules that govern the Physical Disability Evaluation System (PDES) in making its determination. The findings and recommendations of the PEB are supported by substantial evidence and are therefore affirmed. The issues raised in your appeal were responded to by the PEB in its 26 August 2019 memorandum. This Agency concurs with the response provided by the PEB. k. The applicant was honorably discharged from the PRARNG on 29 February 2020, in accordance with paragraph 6-351(12), National Guard Regulation (NGR) 600- 200, Enlisted Personnel Management, dated 31 Jul 2009 (PPOM 14-008 dated 1 June 2015). l. His NGB Form 22 (Report of Separation and Record of Service) is neither filed nor provided; however, his NGB Form 23B, ARNG Retirement Points History Statement shows he completed 8 qualifying years of service towards non-regular retirement. 3. By ARNG regulation (NGB 600-200), paragraph 6-35(l)(12) Soldier found medically unfit due to non-LOD issue with fewer than 15 years of qualified service. 4. Title 38, U.S. Code, Sections 1110 and 1131, permit the VA to award compensation for disabilities which were incurred in or aggravated by active military service. However, an award of a VA rating does not establish an error or injustice on the part of the Army. The Army rates only conditions determined to be physically unfitting at the time of discharge, which disqualify the Soldier from further military service. The Army disability rating is to compensate the individual for the loss of a military career. The VA does not have authority or responsibility for determining physical fitness for military service. The VA may compensate the individual for loss of civilian employability. 5. MEDICAL REVIEW: a. The Army Review Boards Agency (ARBA) Medical Advisor was asked to review this case. Documentation reviewed included the applicant’s ABCMR application and accompanying documentation, the military electronic medical record (AHLTA), the VA electronic medical record (JLV), the electronic Physical Evaluation Board (ePEB), the Medical Electronic Data Care History and Readiness Tracking (MEDCHART) application, and/or the Interactive Personnel Electronic Records Management System (iPERMS). The ARBA Medical Advisor made the following findings and recommendations: b. The applicant is applying to the ABCMR requesting an affirmative line of duty determination (LODD) for a traumatic brain injury and other unspecified condition(s) so that he may use it to obtain benefits from the Veterans Benefits Administration (VBA). He states: “I had order to travel for military training to St. Croix on November 19, 2012, to November 21, 2012. During my return to my house on November 21, 2012, I suffered a car accident with several damages and consequences. I received emergency services and hospitalization. The government and local protocol was to continued government insurance to cover my damage and medical follow-up. My family followed the instruction and I was excused to my next training date on November 26, 2012. However, my family never received guidance of active an LOD to receive my military benefits and follow-up. I never received guidance about this process. Now, Veteran Benefits Administration is denying my claim for service connected because during my training/orders my unit never completed the LOD. My unit provided me support to complete my task until I was unable to continue and request social security benefits. I needed evidence of a defense authority to clarify this error. I attached evidence of my orders and also a co-workers testimony of their visual observation of my accident after completing that day of training.” c. The Record of Proceedings outlines the applicant’s military service and the circumstances of the case. The applicant’s National Guard Report of Separation and Record of Service (NGB Form 22) shows he entered the Army National Guard on 8 January 2013 was honorably discharged from the Alabama Army National Guard on 4 February 2020 Orders published by the Puerto Rico Army National Guard (PRARNG) show he was honorably discharged for the PRARNG effective 29 February 2020 under the provisions paragraph 6-35l(12) {sic – should read 6-35l(8)} of NGR 600-200, Enlisted Personnel Management: Medically unfit for retention per AR 40-501, Standards of Medical Fitness. d. MEDCHART contains a 24 November 2012 hand-written encounter from the Puerto Rico Medical Center which states “25-year-old male patient who suffered MBT pedestrian on 11/22/12 under unknown circumstances.” It notes the applicant had significant head and other injuries. e. MEDCHART also contains a duty limiting temporary physical profile dated 5 June 2013 for “Unspecified condition of brain, cerebellar or brain stem laceration with open pulmonary trauma, cerebral contusion, contusion of forearm, other medical conditions; acquired deformities of knee, loose body in knee.” There is a civilian radiologist’s report of a 12 f. An April 2013 head CT performed for “25-year-old male status post MBT/pedestrian, for follow-up.” Impression: * Encephalomalacic changes, more prominent at the left frontotemporal region, with associated ex vacuo dilatation of the left temporal horn, findings which represent the sequela of prior parenchymal contusions. * No acute intracranial pathology. g. The applicant was placed on a duty limiting permanent physical profile for “Multifocal encephalomalacic changes” on 19 September 2018. This condition is an abnormal softening of brain tissue with a number of varied etiologies of which stroke is the most common: “Encephalomalacia is a type of serious brain damage that results in the softening or loss of brain tissue. Causes of encephalomalacia are often linked to inflammation or hemorrhages that are a consequence of being afflicted by cerebral infarction, cerebral ischemia, infection, craniocerebral trauma, or another injury. Softening may be seen in a localized area or be widespread, depending on the underlying cause. It can affect virtually any part of the brain, possibly damaging tissues of the frontal, occipital, parietal, and temporal lobe. This can present with several motor and sensory deficits ... Symptoms can vary from person to person, often presenting in unique ways depending on the severity and extent of the damage. Extreme cases of encephalomalacia may potentially even lead to terminal coma, depending on the area of brain softening.” (https://www.belmarrahealth.com/encephalomalacia-causes-types-treatment/) h. On 30 October 2018, he requested referral to a non-duty related physical evaluation board (NDR PEB) for this condition. NDR PEBs allow Reserve Component (RC) Service Members who are not on a call to active duty of more than 30 days and who are pending separation for non-duty related medical conditions but desire to remain in their component to enter the Disability Evaluation System (DES) for a determination of fitness. A non-duty related physical evaluation board (NDR PEB) affords these Soldiers the opportunity to have fitness determined under the standards that apply to Soldiers who have the statutory right to be referred to the DES for a duty related medical condition. After 2014, these boards would also look to see if the referred condition(s) were duty related, and if so, return them to the sending organization for entrance into the duty related processes of the DES. i. The PRARNG narrative summary stated his condition was not duty related: “Basis for Non-duty related process: SGT [Applicant], suffered an accident which was impacted by a vehicle while crossing the street which had to be taken to the hospital by different traumas. At the time of the accident SGT [Applicant] was not under military orders.” j. On 9 December 2018, his commander opined on the “Disability Evaluation System (DES) Commander’s Performance and Functional Statement: “Since SGT [Applicant] returned to duty after the accident, his performance is below minimum standards. His decision-making ability, communication skill and mechanical abilities are down to a point that I will not send him on a mission without direct supervision, and as a 88L Marine engineer SGT he should be able to perform inside an engine room with moving parts on a moving platform at sea.” k. On 25 March 2019, the applicant’s informal physical evaluation board (PEB) determined this was an unfitting medical condition for continued military service and that it was not related to his military service: “NDR Case: Soldier was diagnosed with condition after an accident with no date of occurrence provided. The condition is characterized by a local softening of the brain tissue that resulted from injury and inflammation. On 30 October 2018. the Puerto Rico Army National Guard indicated this condition does not meet medical fitness standards. This condition is not compensable because the PEB's review of available military and civilian medical records did not reveal any evidence that the condition was either incurred or aggravated while on active duty. This Soldier is unfit because DA Form 3349, Physical profile limitations associated with this condition prevents him from performing Section 4 functional activities 24f; live and function, without restrictions in any geographic or climatic area without worsening condition. Therefore, the Soldier is unfit.” l. The applicant non-concurred with the PEB and demanded a formal hearing without a personal appearance and representation by regularly appointed counsel. The applicant requested to be found fit for duty. m. The unfit finding was maintained at his 13 August 2019 formal physical evaluation board. n. Though the applicant’s orders show he was to be on temporary duty from 19-22 November 2012, there is no evidence in the supporting documentation, or the electronic records the applicant’s injuries were incurred while the applicant was still in a qualifying duty status. The available records and the applicant’s statement suggests the accident occurred after the completion of his duty day at which time he would not have been in a qualifying duty status. o. The applicant submitted an appeal to the VBA following their initial denial of service connection for multiple injuries apparently sustained in November 2012. He submitted numerous medical documents with his appeal which were not included in this application. He also submitted several buddy statements which are in Spanish. p. The VBA maintained their findings that his conditions were not service connected in their 29 September 2022 rating decision. Their determinations were similar all the claimed conditions. For his head injury: Service connection for skull fracture. A claimant may file a supplemental claim by submitting or identifying new and relevant evidence. New evidence is evidence not previously part of the actual record before agency adjudicators. Relevant evidence means evidence that tends to prove or disprove a matter at issue in a claim (38 CFR 3.2501) Service connection was previously denied for your claimed condition in the Rating Decision dated March 2020. Consequently, you submitted a supplemental claim in-regards-to the aforementioned decision. We have reviewed the evidence of record (to include VAMC San Juan treatment records (2019-2022); and private treatment records from Recinto de Ciencias Medicas (2014-2019), Centro Medico de Puerto Rico (2012), and Dr. Rodriguez- Garcia (2016-2020)) related to your claim. However, the evidence reviewed does not warrant service connection. (38 CFR 3.303, 38 CFR 3.304, 38 CFR 3.307, 38 CFR 3.309, 38 CFR 3.159) We can only establish service connection for death or chronic injuries, including myocardial infarctions and strokes, that occur while performing, or in transit to or from, inactive duty for training. We can also grant service connection for diseases or injuries that occur during active duty for training periods. (38 CFR 3.303, 38 CFR 3.304, 38 CFR 3.6, 38 CFR 3.1) Your ACTIVE duty and RESERVE service treatment records (STRs) were absent of a history for a diagnosis and there is no medical opinion establishing a link to military service. Furthermore, your "reserve" STRs do not contain a line of duty (LOD) determination indicating that this condition was incurred in the line of duty (LOD). (38 CFR 3.303, 38 CFR 3.304, 38 CFR 3.6, 38 CFR 3.1) You also provided a lay and/or buddy statement(s) in which it was noted that you have had difficulty and impairment with your condition. However, the evidence of record does not clearly and factually show that your condition is related to military service. (38 CFR 3.159) Therefore, service connection for your claimed condition remains denied.” q. While the VBA’s findings do not directly affect an Army LODD, they reflect that they also found no evidence the applicant’s injuries were related to his military service. r. It is notable that the VBA referenced treatment records covering his accident - Centro Medico de Puerto Rico (2012) – were unfortunately not available for review. s. It is the opinion of the Agency medical advisor there is insufficient evidence to support an affirmative line of duty determination at this time. BOARD DISCUSSION: 1. After reviewing the application, all supporting documents, and the evidence found within the military record, the Board found that relief was not warranted. The Board carefully considered the applicant's record of service, documents submitted in support of the petition and executed a comprehensive and standard review based on law, policy and regulation. Upon review of the applicant’s petition, available military records and the medical review, the Board concurred with the advising official finding insufficient evidence to support an affirmative line of duty determination at this time. The Board found no evidence in the supporting documentation, or the electronic records the applicant’s injuries were incurred while the applicant was still in a qualifying duty status. The Board determined, based on the opine and evidence provided by the applicant there is insufficient evidence of an error or unjust. The Board agreed, based on the preponderance of evidence conduct during his PEB and the absent of his treatment records, relief is denied. 2. This board is not an investigative body. The Board determined despite the absence of the applicant’s treatment records, they agreed the burden of proof rest on the applicant, however, he did not provide sufficient supporting documentation and his service record has insufficient evidence to support the applicant’s accident occurred during the completion of his duty day and not after for the Board to consider correction of his Army National Guard (ARNG) records to show he was discharged from the ARNG due to “disability” vice being medically unfit for retention. 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. REFERENCES: 1. National Guard Regulation 600-200, Personnel – General, Enlisted Personnel Management, prescribes the criteria, policies, processes, procedures and responsibilities to classify; assign; utilize; transfer within and between states; provides Special Duty Assignment Pay; separation; extension/reenlistment, and appoint to and from command sergeant major Army National Guard (ARNG) enlisted Soldiers. Chapter 6 sets the policies, standards, and procedures to separate enlisted Soldiers from the ARNG. Paragraph 6-35 provides for Separation/Discharge from State ARNG and/or Reserve of the Army and provides a list of reasons, applicability, and codes for administrative separation or discharge from the Reserve of the Army, the State ARNG only, or both. Sub-paragraph 6-35(l)(12) states Soldier found medically unfit due to non- LOD issue with fewer than 15 years of qualified service. RE: 3. Loss Code MG 2. Title 38, U.S. Code 1110 (General - Basic Entitlement) states for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation as provided in this subchapter, but no compensation shall be paid if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. 3. Title 38 U.S. Code 1131 (Peacetime Disability Compensation - Basic Entitlement) states for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during other than a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation as provided in this subchapter, but no compensation shall be paid if the disability is a result of the veteran's own willful misconduct or abuse of alcohol or drugs. //NOTHING FOLLOWS// ABCMR Record of Proceedings (cont) AR20230005881 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1