Hensley v. United States

292 F. Supp. 3d 399
Court of Appeals for the D.C. Circuit·Decided February 22, 2018·No. Civil Action No. 16–1389 (TJK)·Published·Cited by 11 cases

Opinion

TIMOTHY J. KELLY, United States District Judge

Plaintiff John Hensley ("Hensley"), a former Staff Sergeant in the West Virginia Air National Guard, suffered a serious shoulder injury when he fell from an aircraft in 2008. In 2013, he submitted a claim for $100,000 under an insurance program for members of the military who have suffered traumatic injuries, Servicemembers' Group Life Insurance Traumatic Injury Protection ("TSGLI"). The Air Force denied Hensley's claim, concluding that Hensley had not shown that his injury qualified him for TSGLI benefits. Hensley sought review before the Air Force Board for Correction of Military Records (the "AFBCMR" or "Board"), which declined to grant his application. Hensley then brought this lawsuit against the United States (the "Government"), asserting that the AFBCMR's decision should be reversed on the ground that it was arbitrary and capricious in violation of the Administrative Procedure Act ("APA"), 5 U.S.C. §§ 551 et seq.

Hensley and the Government have cross-moved for summary judgment. See ECF No. 9 ("Pl.'s Mot."); ECF No. 13 ("Def.'s Cross-Mot."); see also ECF No. 15 ("Pl.'s Reply"); ECF No. 17 ("Def.'s Reply"). For the reasons explained below, Hensley's motion will be granted in part and denied in part, and the Government's motion will be denied.

I. Background

A. The TSGLI Program and Claims Process

Members of the U.S. armed services are automatically enrolled in the Servicemembers' Group Life Insurance program, although they may opt out. See 38 U.S.C. § 1967 ; Ridgway v. Ridgway , 454 U.S. 46, 50-54, 102 S.Ct. 49, 70 L.Ed.2d 39 (1981) (describing origins of program). TSGLI is an automatic rider to that insurance and covers traumatic injury. See 38 U.S.C. § 1980A ; Austin v. Prudential Ins. Co. of Am. , No. SA-12-CA-473, 2013 WL 12094176, at *2 (W.D. Tex. Apr. 5, 2013).

"To receive TSGLI benefits, a service member must have suffered a 'qualifying loss.' " Austin v. United States , 614 Fed.Appx. 198, 200 (5th Cir. 2015) (quoting 38 U.S.C. § 1980A(a)(1) ). By regulation, the government has promulgated a schedule of losses describing the types of injuries that are covered. 38 C.F.R. § 9.20(f). They include traumatic non-brain injuries "resulting in an inability to perform at least 2 Activities of Daily Living (ADL)." Id. § 9.20(f)(20). "The statute recognizes six ADLs: bathing, continence, dressing, eating, toileting, and transferring (in or out of a bed or chair)." Austin , 614 Fed.Appx. at 200 (citing 38 U.S.C. § 1980A(b)(2)(D) ). "TSGLI will pay $25,000 for each consecutive 30-day period of ADL loss, up to a maximum of $100,000 for 120 consecutive days." Id.

The Fifth Circuit has summarized the TSGLI claims process as follows:

To apply for benefits, a plan participant must file a form SGLV 8600 with his service branch. This form has two parts:
*403Part A, to be filled out by the claimant, and Part B, the "Medical Professional's Statement," in which the claimant's physician must certify the qualifying losses claimed....
The claim is then reviewed by a certifying official at the claimant's branch of service. If that official approves any benefits, he instructs ... the private insurance company that administers the TSGLI program[ ] to pay such benefits and to notify the claimant if any part of the claim has been denied.

Id. at 200. Within a year of the initial decision, service members may appeal in writing "to the office of the uniformed service identified in the decision regarding the member's eligibility for the benefit." 38 C.F.R. § 9.20(i)(1).

Benefits decisions may be further appealed to the relevant board for correction of military records, such as the AFBCMR. See, e.g., Blackwood v. United States , 187 F.Supp.3d 837, 839 (W.D. Ky. 2016). Such boards may act "to correct an error or remove an injustice." 10 U.S.C. § 1552(a)(1). In AFBCMR proceedings, the "applicant has the burden of providing sufficient evidence of material error or injustice." 32 C.F.R. § 865.4(a). The AFBCMR panel appointed to hear the case may request advisory opinions and information from other Air Force officials, in which case the applicant will be given the opportunity to respond. See id. § 865.4(a)(1), (b).

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Hensley v. United States, 292 F. Supp. 3d 399 (D.C. Cir. 2018).

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