Delayed/Denied TSGLI Claim
Traumatic Injury Protection (“TSGLI”) is a rider to Servicemembers’ Group Life Insurance coverage. If you served in the military from October 7, 2001 – Present day and you experienced a qualifying loss (on or off duty) during your active service (see below for a complete list of qualified servicemembers) you may be entitled to TSGLI benefits. A servicemember may be eligible for TSGLI benefits whether the servicemember was injured on or off duty. Congress enacted TSGLI benefits in 2005. In 2012, Congress removed the TSGLI claim requirement that a servicemember be injured while on duty serving overseas. Any servicemember enrolled in SGLI coverage is automatically enrolled in TSGLI coverage. U.S. servicemembers that suffer a traumatic injury may be eligible for a TSGLI benefits up to $100,000.
Many service members are unaware of TSGLI coverage. Accordingly, TSGLI benefits are available to a service member that meets certain eligibility requirements. At this time, the DOD requires Hospitalization and difficulty performing activities of daily living (ADLs). The Department of Defense is responsible for deciding who is eligible for benefits. The TSGLI application process can be challenging due to the length of the application and the evidence and proof requirements. Sometimes, even once adequate evidence has been submitted, the DOD can deny your claim when it should have been paid. A life insurance attorney can help investigate whether your claim was wrongfully denied and assist in appealing.
Filing a TSGLI Claim
A TSGLI benefit payment can be claimed by the injured service member, guardian, power of attorney, or military trustee. The claim is filed when the required TSGLI benefits application has been completed. Additionally, a healthcare provider must complete Part B of the form. Part B should provide details of the service member’s injuries. Also, the service member’s injuries must qualify the service member for the TSGLI benefit. The service member must also provide medical documentation of their injury(s) and an explanation of how each injury occurred.
TSGLI Claim Requirements
- Incurred severe loss as a result of traumatic injuries;
- Must be insured by SGLI and experienced a traumatic injury on or after October 7, 2001 to present date;
- Incurred a scheduled loss;
- That loss must be a direct result of a traumatic injury;
- Must have suffered the traumatic injury prior to midnight of the day that you separate from the uniformed services;
- Must have suffered a scheduled loss within 2 years (730 days) of the traumatic injury; and
- If deceased: must have survived for a period of not less than seven (7) full days from the date of the traumatic injury
Medical Documentation
- Occupational/physical therapy report (ADL documentation)
- Neurological reports (TBI/ADL documentation)
- OR report (amputation)
- Hearing test results (for hearing loss)
- Eye test results (for sight loss)
- Speech test results (for speech loss)
- Patient discharge summaries
- Medical summary and/or history
- Patient movement request
- Radiographic reports (X-Ray, MRI, ultrasound, etc.)
- Accident report
- Line of duty (LOD)
- Medical/physical evaluation board (MEB/PEB)
- Other diagnostic test results (e.g., lab reports, etc.)
- Pertinent documents demonstrating injury type and duration of ADL loss.
Loss of Activities of Daily Living
Service members file TSGLI claims for benefits related to the Loss of Activities of Daily Living (ADLs). A service member is considered eligible if the member is unable to independently perform at least 2 of 6 ADLs. The service member’s inability must last at least 30 consecutive days. Also, it must be in increments of 30 days up to 120 days in duration.
Generally speaking, inability means that the service member requires assistance to safely perform activities as a result of the injury. What does the DOD require you to prove? Importantly, the DOD requires a service member to receive a letter from a medical professional. Furthermore, the medical professional must certify a service member’s ADL loss. Specifically, a medical professional must certify your injury and term for disability.
The Six (6) ADLS
Bathing, Continence, Dressing, Eating, Toileting, Transferring
TSGLI Payment Increments
TSGLI payments are given in $25,000 increments. Moreover, a service member is given a payment based upon the number of consecutive days that the service member experiences ADL loss. See blow:
- 30th consecutive day of ADL loss = $25,000.00
- 60th consecutive day of ADL loss = $50,000.00
- 90th consecutive day of ADL loss = $75,000.00
- 120th consecutive day of ADL loss = $100,000.00
Frequently Asked Questions
What is the premium for TSGLI?
For most service members, the premium for TSGLI is a flat rate of $1 per month.
What service members do TSGLI claims cover?
- Active duty
- Funeral Honors Duty
- National Guard
- One-Day Muster Duty
- Reserve
Does TSGLI cover injuries that occur off duty?
Yes. TSGLI may cover injuries that occur while on duty and off duty.
What is the definition of a traumatic injury?
A traumatic injury is physical damage to a living body that is caused by a traumatic event. Moreover, it does not include a mental disorder or a mental or physical illness or disease, except if the physical illness or disease is caused by a pyogenic infection, biological, chemical, or radiological weapons, or accidental ingestion of a contaminated substance.
Nevertheless, a traumatic injury event is the application of external force, violence, chemical, biological, or radiological weapons, or accidental ingestion of a contaminated substance. Specifically, the injury must cause physical damage to a living service member.
What types of injuries are NOT covered under TSGLI?
- Intentionally self-inflicted injuries
- Attempted self-inflicted injury
- Injury relating to illegal or controlled substance, if it was not administered or consumed on the advice of a medical doctor
- Diagnostic procedures
- Preventive medical procedures such as inoculations, medical or surgical treatment for an illness or disease, or any complications arising from such procedures or treatment.
- A traumatic injury sustained while committing or attempting to commit a felony
- Lastly, a physical or mental illness or disease (not including illness or disease caused by a wound infection, a chemical, biological, or radiological weapon, or the accidental ingestion of a contaminated substance)
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