Hayes v. United States

District Court, District of Columbia·Decided July 19, 2022·No. Civil Action No. 2021-0362·Published

Opinion

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA

PETER HAYES,

Plaintiff, v. Civil Action No. 21-362 (JEB)

UNITED STATES OF AMERICA, Defendant.

MEMORANDUM OPINION

In 2010, Plaintiff Peter Hayes, an enlisted member of the Army, injured himself in a motorcycle accident in South Carolina while off duty. Years later, he submitted a claim for insurance benefits under the Servicemembers’ Group Life Insurance Traumatic Injury Protection Program (referred to as TSGLI). As a covered member, Hayes is entitled to some level of TSGLI benefits if traumatic injuries rendered him unable to independently perform at least two enumerated “activities of daily living,” such as bathing or dressing, for at least 30 consecutive days. After a litany of applications, requests for reconsideration, and administrative appeals, the U.S. Army Board for the Correction of Military Records ultimately approved an award of $50,000, but denied Plaintiff an additional $25,000 because he had not shown that his loss of independence continued for an additional 30 days (for a total of 60 consecutive days). Now, twelve years after the accident, Hayes is in federal court still pursuing the additional $25,000 he believes he is owed, and he and Defendant United States have cross-moved for summary judgment. Because the Board applied the correct evidentiary standard and its determination was not arbitrary or capricious, the Court will grant the Government’s Motion.

I. Background Before delving into the facts and procedural history of this case, the Court will provide a brief overview of the relevant regulatory backdrop. In 2005, Congress created the TSGLI Program to provide monetary assistance to servicemembers who suffer traumatic injuries. See Pub. L. No. 109-13, § 1032(a)(2), 119 Stat. 231 (2005); accord Sorkness v. United States, No. 17-2248, 2019 WL 4451990, at *1 (D.D.C. Sept. 17, 2019). Under the Program, servicemembers are “automatically . . . insured for traumatic injur[ies],” and a member who suffers a “qualifying loss” is entitled to payments ranging from $25,000 to $100,000 depending on “the severity of the qualifying loss.” 38 U.S.C. § 1980A(a), (d). The statute and implementing regulations, in turn, define qualifying losses as including a traumatic injury resulting in the inability of the servicemember to perform at least two activities of daily living (ADLs) for at least 30 consecutive days. Id. § 1980A(b); see 38 C.F.R. § 9.20. The loss of such ADLs for 30 days entitles a claimant to an award of $25,000. See 38 C.F.R. § 9.20(f)(20). Relevant here, if the servicemember’s inability to perform at least two ADLs extends to 60 consecutive days, the size of the award increases by $25,000. Id. Finally, if the loss of function is due to a traumatic brain injury, claimants can recover an additional $25,000.

On the evening of September 10, 2010, Hayes crashed his motorcycle in South Carolina while not wearing a helmet. See ECF No. 25 (Sealed Joint Appendix) at 51. According to the hospital records, “Alcohol was involved.” Id. At the time of the accident, Plaintiff was an active-duty soldier in the U.S. Army and eligible for TSGLI benefits, even though he was not performing a military function that night. Id. at 926; see ECF No. 20-1 (Def. Cross-Motion) at 5; ECF No. 20-2 (TSGLI, A Procedural Guide) Part 1, at 5 (“TSGLI provides for payment to Servicemembers who are severely injured (on or off duty) as the result of a traumatic event and

suffer a loss that qualifies for payment under TSGLI.”). Plaintiff was admitted to the hospital, where he was diagnosed with several injuries, including fractures in his right wrist and skull. See Sealed JA at 51–52. Three days later, he had surgery on his wrist. Id. at 38, 56–58. The next day — September 14, just four days after the accident — Hayes was discharged from the hospital. Id. at 49–50. At the time of his discharge, Plaintiff was “up walking around,” and he was “alert and oriented” with “no focal neurologic deficits.” Id. at 49. In the ensuing months, he attended various medical and therapy appointments as his recovery proceeded. The Court will not detail that recovery at length here, choosing to provide the relevant details as necessary to the legal analysis below.

Fast forward several years to February 2014, when Plaintiff first applied for TSGLI benefits. Id. at 1–5, 14–15. His application consisted of a completed form and a statement from Terri Burns, a registered nurse who did not observe Hayes’s recovery immediately after the accident but instead “reviewed the patient’s medical records.” Id. at 6–13. In this filing, Hayes sought $50,000. Id. at 15. The claim was partially approved, and he was awarded $25,000 for the loss of the ability to bathe and dress for at least 30 consecutive days after the accident due to non-brain-related traumatic injuries. Id. at 882, 884. But Plaintiff’s claim for the loss of multiple ADLs for at least 60 days, and the accompanying additional award, was denied. Id.

Hayes then appealed the partial denial of his claim. Id. at 884–924. In that appeal, he requested an additional payment of $25,000 for his loss of ADLs lasting 60 days, as well as another $25,000 (for a total of $75,000) on the ground that his impairments were in fact related to a traumatic brain injury. Id. at 886. The TSGLI office denied additional relief, finding insufficient evidence that Plaintiff was unable to perform at least two ADLs for 60 consecutive days and that his limitations were due to a traumatic brain injury. Id. at 925–30. Undeterred,

Hayes asked the Army to reconsider his claim and then again supplemented his request. Id. at 935–51. This time around, the TSGLI Certifying Official awarded an additional $25,000 because Plaintiff had now demonstrated that his loss of functions for 30 days was in fact caused by a traumatic brain injury. Id. at 1783–85. Hayes was once again denied the final $25,000, however, because the records did not establish that his loss of ADLs extended to 60 days. Id.

Having been awarded $50,000 but still seeking the additional $25,000, Plaintiff submitted a third application for benefits. Once again, his request was denied. Id. at 2664. In late 2015 — now five years removed from the accident — Hayes submitted one more appeal. The TSGLI Appeals Review Panel unanimously voted to recommend denial of the appeal, and the Adjutant General, U.S. Army Human Resources Command, notified Plaintiff of this decision. The Adjutant General explained in a detailed letter that because “the medical record indicates he had only loss of bathing at Day 56 and was independent for basic activities of daily living by Day 61,” Plaintiff did not satisfy the requirements for an additional payment. Id. at 4026–32.

Finally, Hayes applied to the U.S. Army Board for the Correction of Military Records, alleging that the supporting records demonstrated that he had required assistance to carry out multiple ADLs beyond the 60-day mark. Id. at 4146. The Board’s medical advisor reviewed the relevant records and found that there was no documentation supporting such a claim. Id. at 6061. The Board thus denied relief. Id. In 2021, Hayes filed this lawsuit, in which the parties have now cross-moved for summary judgment. II. Legal Standard Plaintiff invokes the Administrative Procedure Act, 5 U.S.C. § 701 et seq., to challenge the Board’s decision. Summary judgment is one appropriate mechanism for adjudicating claims under the APA. See, e.g., Loma Linda Univ. Med. Ctr. v. Sebelius, 684 F. Supp. 2d 42, 52

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