TSGLI, also known as Servicemembers’ Group Life Insurance Traumatic Injury Protection, is a form of insurance that provides short-term financial support to help eligible service members recover from a traumatic injury. This insurance applies no matter if the injury occurred in the line of duty or off duty.
However, not every injury sustained may qualify for TSGLI payments, and more importantly, these benefits are not always the easiest to calculate. In fact, in most instances, you need to work with an experienced V.A. attorney to help you get the maximum compensation you deserve.
TSGLI Eligibility Requirements
To qualify for TSGLI, Servicemembers’ Group Life Insurance (SGLI) must have insured you at the time you experienced your traumatic injury unless the injury occurred from October 7, 2001, through November 30, 2005.
Next, you must meet these requirements:
- You have a scheduled loss that directly results from your traumatic injury,
- You suffered this scheduled loss within two years of the traumatic injury,
- You suffered the injury before midnight on the day you left the service,
- You survived for not less than seven full days from the date of the traumatic injury, and
- You were a National Guard member, on funeral-honors duty, a reservist, an active-duty military member, or on a one-day muster duty at the time of your injury.
Injuries Included by TSGLI
Once you meet the above requirements, you will need to determine if TSGLI covers your injury.
The injuries that qualify for TSGLI compensation are referred to as scheduled losses and often include:
- Sensory losses, such as sight, speech, or hearing
- Paralysis of limbs
- Facial reconstruction
- Inability to perform activities of daily life
- In-patient hospitalization
- Genitourinary losses
Additionally, you should note that a service member can qualify for TSGLI payments no matter where the injury occurred or if the member was injured off duty.
Injuries Excluded by TSGLI
Although TSGLI covers numerous injuries, to qualify for TSGLI benefit payments:
- The injury cannot be self-inflicted or on purpose.
- The injury cannot be the result of an attempt at self-injury.
- The injury cannot involve the use of an illegal drug or a controlled substance that was taken without a medical doctor’s advice.
- The injury cannot result from surgical treatment or medical treatment of a disease or illness.
- The injury cannot occur while committing or trying to commit a felony.
- The injury cannot result from a physical or mental illness or disease. However, this excludes conditions or diseases caused by a wound infection, a chemical, biological or radiological weapon, or accidentally swallowing a contaminated substance.
Life Insurance Benefits Through TSGLI
The premium for TSGLI is usually a flat rate of one dollar per month for most service members. However, the amount you will get in support of your traumatic event will depend on the type of injury you sustained, with most reimbursements often ranging from $25,000 to $100,000. Yet, these payments can go below $25,000, but they cannot exceed $100,000, and multiple injuries can combine if they result from the same accident.
Even though TSGLI will automatically cover you if you signed up for full-time SGLI, to get these payments, including retroactive TSGLI payments, you need to apply for them by filling out an Application for TSGLI Benefits (SGLV 8600).
Calculating TSGLI Benefits
Although the government provides a Schedule of Losses that outlines the injuries covered under TSGLI and the amount payable for each injury, calculating these benefits is not as straightforward as many people expect.
First of all, three scenarios govern payments under TSGLI:
- A single injury that resulted from a single traumatic event
- Multiple injuries that resulted from a single traumatic event
- Multiple injuries resulting from multiple traumatic events
As a result, if a member suffers multiple injuries from a single traumatic event, the member’s benefits will be the amount of the highest paying scheduled loss up to a maximum of $100,000. To see this in practice, let’s say a service member permanently lost sight in both of their eyes due to a traumatic event. The benefits under the schedule for permanent loss of sight in both eyes are $100,000.
Yet, let’s also say this service member lost a foot directly from a traumatic injury due to this same traumatic event. The benefit for a loss of foot is $50,000. However, according to the regulations, the service member will only be paid $100,000 and not the combined total because they can only get the higher paying scheduled loss.
Another complicated calculation that service members may encounter is regarding a burn injury.
When a member suffers a burn, they are eligible for benefits if they meet specific standards:
- A second degree (partial thickness) or worse burn that covers over 20 percent of the body, including the face and head
- A second degree (partial thickness) or worse burn that covers over 20 percent of the face only
However, to determine if a member meets these standards, they need to complete a facial burn calculation that converts head burns as a percentage of Total Body Surface Area (TBSA) into a percentage of the face alone. This calculation will allow these members to determine if they meet the standard of a second-degree burn to 20 percent of the face.
Yet, you must enter the correct numbers to complete this calculation, primarily since this burn calculator is based on the face being approximately half of the head. Consequently, if the member in question has burns on the back of the head and not on the face, it will require them to estimate how much of the face is burned compared to the TBSA of the head and use this number instead in the calculation. But if individuals do not have experience with these calculations, they can enter the wrong amount, which can impact their payment.
As a result, calculating these benefits requires a thorough understanding of the rules and experience dealing with these calculations. That is why it is often in your best interest to work with a V.A. attorney who has experience with these TSGLI calculations. A lawyer will usually have the training and the knowledge needed to accurately run these numbers to figure out the precise amount of benefits you can receive.
Denial of a TSGLI Claim
Service members must also deal with claim denials. Unfortunately, there are numerous reasons why the United States Department of Veterans Affairs (V.A.) may deny a claim.
Incorrect Information in the Paperwork
To obtain TSGLI benefits, you must fill out the required paperwork correctly. However, this paperwork often involves a great deal of information and details. If you miss any of these sections or prepare them incorrectly, the V.A. may deny your claim. That is why you must work with a knowledgeable attorney that can fill out everything correctly.
Not Meeting the Requirements
Another common reason for denied benefits is not meeting the TSGLI eligibility standards. The V.A. will not automatically pay you for your injuries. To get your benefits, you will first need to meet the mandatory requirements set out by the V.A. Fortunately, when you work with an attorney who has experience handling these claims, they can look over your claim and verify whether or not you meet these standards.
Not Enough Supporting Documents to Prove Your Claim
To support a claim of disability, you need to present at least two ADL’s (activities of daily living) that you can no longer perform because of your injuries. This means you will need enough medical documentation to support your disability claim. You may not receive these benefits if you do not include this documentation.
In general, this additional information often includes:
- A patient discharge summary
- Operative reports
- Medical summaries
- Medical histories
- Accident reports
- Occupational therapy reports
- Physical therapy reports
However, when you work with a skilled attorney, these legal professionals can make sure to put together the documentation and evidence you need to prove your losses and go after the money you need.
How to Appeal a Denied TSGLI Claim
The V.A. is notorious for denying TSGLI claims that it should cover. However, if your claim was rejected, it does not mean that all hope is lost. In many instances, you may be able to appeal the denial or ask for reconsideration.
Typically, if a member gets their TSGLI payments denied, they will receive a denial letter. This letter will lay out instructions on filing an appeal and completing the appropriate forms. These members will then need to complete the forms and submit any new evidence that can help them prove their injury. Once the TSGLI branch receives all the information, the member’s branch of service or its higher appeal authority will ultimately decide on the case.
Because appeals often require the strongest medical documentation possible to prove a claim and will also need the member to set forth strong reasons why the initial determination was wrong, work with an experienced attorney who has won these cases before, and knows what evidence to present to succeed in an appeal.
Differences Between a TSGLI Claim and a Disability Claim
A TSGLI claim and a disability claim are different and separate claims. Typically, an injured veteran or service member will file a disability claim with the V.A. to receive disability benefits. These benefits come in the form of monthly payments given out to veterans who have incurred a disease or suffered an injury while on active duty.
Some of the more common medical conditions that qualify for disability compensation include head and back injuries, heart disease, broken bones, cancer, sleep disorders, anxiety, depression, arthritis, PTSD, and Gulf War Illness.
However, if a service member suffered a traumatic injury that qualifies for both disability and TSGLI benefits, these individuals may receive a one-time lump sum payment for the TSGLI claim and a monthly disability payment.
Yet, to determine if both these benefits apply in your situation, you should reach out to a skilled V.A. lawyer. These attorneys can review your medical condition and the eligibility requirements for both claims and determine what benefits you can pursue.
How Can a Lawyer Help You With Your TSGLI Claim and Calculations?
No matter if you are an active duty member, National Guard member, or a reservist, you may be eligible to receive significant TSGLI benefits for the injuries and losses you endured. More importantly, you may be able to receive these benefits even if you were not injured while on duty.
However, to ensure you get the benefits you need and the paperwork and calculations are done properly, it is recommended you work with a skilled V.A. lawyer.
A V.A. attorney can play a crucial role in the TSGLI claims process by:
- Managing your TSGLI application
- Managing your ongoing medical care
- Obtaining the records that will help form the basis of your TSGLI claim
- Gathering medical evidence to support your TSGLI claim
- Correctly calculating TSGLI benefits
- Preparing and submitting appeals following your TSGLI denial
If you believe you deserve TSGLI benefit payments, do not wait any longer to secure the legal help you need. Instead, contact an experienced V.A. attorney today for a free consultation and let these attorneys show you how they can help.