RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX		BRANCH OF SERVICE: army
CASE NUMBER:  PD0900008 		COMPONENT: reserve
BOARD DATE: 20090609		SEPARATION DATE: 20060803

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SUMMARY OF CASE:  This covered individual (CI) was an Army 2LT/O1E medically separated from the Army in 2006 after 7 years of active service.  The medical basis for the separation was chronic right hip pain and Post Traumatic Stress Disorder (PTSD).   CI was an enlisted Army reservist (SSG) medically evacuated from Iraq for a right hip injury.  CI had abnormal imaging studies and arthroscopic surgery did not resolve his pain.  Due to his hip profile, CI could not attend Officer Basic Course and it appears that as the MEB evaluation started, multiple symptoms of PTSD and depression came to light and PTSD with major depression was diagnosed.  CI was referred to the PEB, found unfit and separated at 10% disability for his hip and 0% for his PTSD.  Both the PEB and VA rated the right hip at 10%.  The PEB specifically noted that non-compensable diagnosis (alcohol dependence) and family issues were considered in the final 0% rating of PTSD.  The VA rated PTSD as 50%.  The VA also rated non-unfitting conditions of hypertension and left shoulder impingement each at 10%.  The CI contends that PTSD and Major Depression were not rated, or rated at 0% by the PEB, and that the VA rated him at 50% (for PTSD/depression).

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BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  Hypertension and left shoulder impingement are rated by the VA, but neither would be unfitting and are not contended. The VA rated the CI’s right hip at 10% under a similar code to the PEB, and this is not contended. 

Regarding PTSD, the PEB specifically mentioned ‘non-compensable diagnosis and family issues which are considered in the final rating.’  There was likely heavy reliance on the commander’s comments indicating disagreement with adding PTSD and depression to the board proceedings and that CI was trying to end his career due to marital issues, depression and substance abuse.  The commander noted that no physical issues interfered with CI’s duties.  CI clearly met the diagnostic criteria for both PTSD and depression and they were found to be unfitting by the PEB.  Marital issues, depression and substance abuse as noted by the commander are frequent manifestations of PTSD and both military and VA psychiatrists opined that CI’s alcohol abuse was self-medication for the CI’s mental health conditions.  The Board therefore did not support rating deductions for either alcohol dependence (non-compensable diagnosis) or family issues.  Appling the VASRD General Rating Formula for Mental Disorders, the signs and symptoms noted in the military records validate between a 30% and 50% rating.  Applying the signs and symptoms from the VA detailed psychiatric examination of 20070301 (~7 months following service discharge) the VA rated the CI at 50% by schedule criteria alone.  The VA did not rely on §4.129, Mental disorders due to traumatic stress, which calls for an initial minimum 50% rating on Service discharge until a follow-up evaluation.  The Board unanimously agreed that the 20070301 evaluation was the best indicator for CI’s disability at 6-months post-service discharge.  The Board did not agree with the VA’s 50% rating of that evaluation.  The Board independently rated the VA mental health evaluation and by a majority rated the CI under code 9411 at 30%.  The single voter for dissent (recommended rating PTSD/depression at 50%) elected not to submit a minority opinion.  

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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows; TDRL at 60% for 6 months following the CI’s prior medical separation (PTSD at minimum of 50% IAW §4.129 and DoD direction), and then a permanent PTSD rating of 30% for a combined 40% disability retirement as below.

Unfitting Condition	VASRD Code	TDRL Rating	Permanent
Rating	
Chronic Right hip pain due to labral tear, onset while deployed to Iraq	5009-5003	10%	10%	
PTSD associated with depression arising from wartime duty in Iraq	9411	50%	30%	
COMBINED	60%	40%	

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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090114, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veteran's Affairs Treatment Record.