22 December 2005
Source: http://www.access.gpo.gov/su_docs/aces/fr-cont.html
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[Federal Register: December 22, 2005 (Volume 70, Number 245)]
[Rules and Regulations]
[Page 75940-75949]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr22de05-8]
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 9
RIN 2900-AM36
Traumatic Injury Protection Rider to Servicemembers' Group Life
Insurance
AGENCY: Department of Veterans Affairs.
ACTION: Interim final rule.
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SUMMARY: The Department of Veterans Affairs (VA) is issuing this
interim final rule to implement section 1032 of the ``Emergency
Supplemental Appropriations Act for Defense, the Global War on Terror,
and Tsunami Relief, 2005,'' (Public Law 109-13). Section 1032 of Public
Law 109-13 establishes an automatic traumatic injury protection rider
provision to Servicemembers' Group Life Insurance (SGLI), effective
December 1, 2005, providing automatic insurance for any SGLI insured
who sustains a serious traumatic injury as prescribed by the Secretary
of Veterans Affairs in collaboration with the Secretary of Defense that
results in certain losses prescribed by the Secretary of Veterans
Affairs in collaboration with the Secretary of Defense. This rule
specifies the losses for which the traumatic injury benefit (TSGLI)
will be paid and the amount of the TSGLI benefit payable for each loss.
Section 1032(c)(1) of Public Law 109-13 also provides for the
payment of TSGLI benefits to service members who experienced a
traumatic injury between October 7, 2001, and the effective date of
section 1032 of Public Law 109-13, i.e., December 1, 2005, if the loss
was a direct result of injuries incurred in Operation Enduring Freedom
or Operation Iraqi Freedom.
DATES: Effective Date: This interim final rule is effective December
20, 2005. Comments must be received on or before January 23, 2006.
Applicability Date: VA will apply this rule to injuries incurred in
Operation Enduring Freedom or Operation Iraqi Freedom on or after
October 7, 2001, through and including November 30, 2005, and to all
injuries incurred on or after December 1, 2005.
ADDRESSES: Mail or hand deliver written comments to: Director,
Regulations Management (00REG1), Department of Veterans Affairs, 810
Vermont Ave., NW., Room 1068, Washington, DC 20420; or fax comments to
(202) 273-9026; or e-mail comments through http://www.Regulations.gov.
Comments should indicate that they are submitted in response to ``RIN
2900-AM36.'' All comments received will be available for public
inspection in the Office of Regulations Management, Room 1063B, between
the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday (except
holidays). Please call (202) 273-9515 for an appointment.
FOR FURTHER INFORMATION CONTACT: Gregory Hosmer, Senior Insurance
Specialist/Attorney, Department of Veterans Affairs Regional Office and
Insurance Center, P.O. Box 8079, Philadelphia, Pennsylvania 19101,
(215) 842-2000 ext. 4280.
SUPPLEMENTARY INFORMATION: TSGLI was designed to provide severely
injured service members who suffer a loss as a direct result of a
serious traumatic injury, such as a loss of an arm or leg, with
monetary assistance to help the member and the member's family through
an often long and arduous treatment and rehabilitation period. In many
instances, the family of a member who suffers a traumatic loss in the
service of his or her country must physically relocate in order to be
with the member during this period in order to provide the member with
emotional support. Relocating an entire family is not only disruptive
but can and does result in economic hardship to the member and the
member's family brought on by new and/or additional living expenses,
and in some cases the loss of a job. TSGLI helps to lessen that
economic burden by providing immediate financial relief.
Traumatic injury protection under SGLI (TSGLI) is modeled after
commercial Accidental Death and Dismemberment (AD&D) insurance
coverage, specifically, the ``dismemberment'' portion of the coverage,
although as we explain below, it deviates in some respects from the
commercial AD&D model to account for the unique needs of military
personnel. We have relied on commercial AD&D policies as a basis for
the TSGLI program for the following reasons. According to 38 U.S.C.
1980A(a), TSGLI is a ``rider'' to the existing SGLI group policy, which
the Secretary of Veterans Affairs purchased from a commercial life
insurance company, Prudential Insurance Company of America, on behalf
of service members. 38 U.S.C. 1966. SGLI premiums after the first
policy year are readjusted by the insurance company issuing the policy
``on a basis determined by the Secretary [of Veterans Affairs] in
advance of such year to be consistent with the general practice of life
insurance companies under policies of group life insurance issued to
large employers.'' AD&D policies are often a rider to group life
insurance policies offered by commercial life insurance companies. In
addition, VA is obligated to manage the TSGLI program ``on the basis of
sound actuarial principles,'' 38 U.S.C. 1980A(e)(4) and (5), and these
AD&D models have proven to be actuarially sound. Therefore, these rules
implementing the TSGLI program are based on commercial AD&D policies,
which have a successful track record, because TSGLI is a rider to a
group life insurance policy purchased from a commercial life insurance
company and because AD&D policies are frequently provided as a rider to
a commercial life insurance policy.
We are setting forth the rules for the TSGLI program in a new
regulation at 38 CFR 9.20. These rules were drafted in collaboration
with the Department of Defense (DoD) as required by statute. We have
added definitions relevant to the TSGLI program at 38 CFR 9.1(k)-(q).
The term ``activities of daily living'' is defined in 38 U.S.C.
1965(11), as added by section 1032(a)(1) of Public Law 109-13, and we
have restated the definition in 38 CFR 9.1(k) because it is a technical
term that may not be readily understood by the general public. We have
added to the statutory definition of ``transferring'' in 38 CFR
9.1(k)(6) the phrase ``in or out of bed or chair with or without
equipment,'' in order to better explain the meaning of the term. We
have defined pyogenic infection in 38 CFR 9.1(l) to mean ``a pus-
producing infection.'' The definitions of contaminated substance and
chemical, biological and radiological weapons in 38 CFR 9.1(m) through
(p) are based on various sources, including the National Center for
Biotechnical Information, the National Library of Medicine, the
National Institutes of Health, the DoD Dictionary of Military Terms,
and commercial insurance industry sources. We have reworded the
definitions for purposes of consistency and clarity.
We have defined ``attending medical professional'' in 38 CFR 9.1(q)
to mean a licensed physician, optometrist, nurse practitioner,
registered nurse, or physician assistant.
We have defined the term ``traumatic event'' in 38 CFR 9.20(b)(1)
to mean ``the application of external force, violence, chemical,
biological, or
[[Page 75941]]
radiological weapons, or accidental ingestion of a contaminated
substance causing damage to a living body.'' TSGLI coverage, however,
is limited to events occurring on certain dates. TSGLI is effective on
December 1, 2005, as provided by section 1032(d)(1) of Public Law 109-
13, 119 Stat. 260. However, any service member who experienced a
traumatic injury between October 7, 2001, and the effective date of
section 1032, i.e., December 1, 2005, is eligible for TSGLI coverage if
the loss was a direct result of injuries incurred in Operation Enduring
Freedom or Operation Iraqi Freedom under section 1032(c)(1) of Public
Law 109-13. Therefore, as explained in Sec. 9.20(b)(1) and (2), the
term ``traumatic event'' refers to a traumatic injury occurring on or
after December 1, 2005, or on or after October 7, 2001, and through and
including November 30, 2005, if the scheduled loss is a direct result
of a traumatic injury incurred in Operation Enduring Freedom or
Operation Iraqi Freedom. For purposes of this rule only, we have
defined the terms ``incurred in Operation Enduring Freedom'' and
``incurred in Operation Iraqi Freedom'' in 38 CFR 9.20(b)(2) to mean
that a service member was deployed outside the United States on orders
in support of Operation Enduring Freedom or Operation Iraqi Freedom or
served in a geographic location that qualified the service member for
the Combat Zone Tax Exclusion under 26 U.S.C. 211.
We explain in 38 CFR 9.20(b)(3) that the term ``traumatic event''
does not include a surgical procedure in and of itself because the
commercial AD&D models we reviewed do not provide coverage for injury
caused by a surgical procedure in and of itself. For example, if a
service member has surgery for a disease such as diabetes, which is not
covered by Sec. 9.20, requiring amputation of a leg, the surgery would
not be considered a traumatic event and TSGLI would not be payable for
the loss. However, if a service member undergoes surgery for injuries
caused by an explosive device, resulting in amputation of a leg, TSGLI
would be payable for the loss because it is the result of a traumatic
event, i.e., the detonation of the explosive device, not the surgery.
We have defined the term ``traumatic injury'' in 38 CFR 9.20(c)(1)
to mean ``physical damage to a living body that is caused by a
traumatic event, as defined in Sec. 9.20(b).'' In Sec. 9.20(c)(2), we
explain that the term does not include damage to a living body caused
by a mental disorder or mental or physical illness or disease, except
if the physical illness or disease is caused by chemical, biological,
or radiological weapons or accidental ingestion of a contaminated
substance. In several precedent opinions, the VA General Counsel has
addressed the meaning of the term ``injury'' for purposes of 38 U.S.C.
101(24) and we believe that the discussion of the plain meaning of the
term in these opinions is helpful in defining ``traumatic injury'' for
purposes of 38 U.S.C. 1980A. The General Counsel has explained that the
term ``injury'' refers to the results of an external trauma rather than
a degenerative process. VAOPGCPREC 4-2002, para. 7. The term ``trauma''
is frequently defined with reference to external force or violence.
VAOPGC 6-86 (1-31-86). The term ``disease,'' on the other hand, refers
to some type of internal infection or degenerative process. VAOPGCPREC
86-90. Based upon these General Counsel opinions, we have defined
``traumatic injury'' as damage to a living body that is caused by the
application of external force, violence, or chemical, biological, or
radiological weapons or accidental ingestion of a contaminated
substance. In accordance with these opinions, we have also defined the
term ``traumatic injury'' in 38 CFR 9.20(c)(2) to exclude damage to a
living body caused by a mental disorder or illness or disease, whether
physical or mental in nature, except if the physical illness or disease
is caused by chemical, biological, or radiological weapons or
accidental ingestion of a contaminated substance. See Winn v. Brown, 8
Vet. App. 510, 516 (1996) (personality disorder is not disease under 38
U.S.C. 1110 and 1131).
We have defined ``traumatic injury'' in Sec. 9.20(c)(2)(ii) to
include physical illness or disease caused by a pyogenic infection,
chemical, biological, or radiological weapons, or accidental ingestion
of a contaminated substance because including immediate traumatic harm
due to those unique hazards of military service is consistent with the
purpose of TSGLI. Because the process by which such hazards produce
immediate harm may be characterized as a disease process, we specify in
Sec. 9.20(c)(2)(ii) that diseases resulting from those hazards are
within the definition of ``traumatic injury.''
Section 9.20(c)(3) states that, for purposes of this section, all
traumatic injuries will be considered to have occurred at the same time
as the traumatic event. We believe that inherent in the term
``traumatic injury'' is the notion that the injury occurs immediately.
This is also the case with regard to the application of chemical,
biological, and radiological weapons and accidental ingestion of a
contaminated substance because the physical damage resulting in a
covered loss would generally occur immediately and require prompt
medical treatment.
Section 9.20(d) discusses the eligibility requirements for payment
of traumatic injury protection benefits. Section 1980A(c) of title 38,
United States Code, provides that TSGLI payments may be made only if:
(1) A member is insured under SGLI when the traumatic injury is
sustained; (2) the loss results directly from that traumatic injury and
from no other cause; and (3) the member suffers the loss before the end
of a period that begins on the date on which the member sustains the
traumatic injury. Section 1980A(h) of title 38, United States Code,
states that coverage for TGSLI ceases at midnight on the date of the
member's separation from the uniformed service. Section 9.20(d)(1) and
(2) of title 38, Code of Federal Regulations, as added by this interim
rule, restates 38 U.S.C. 1980A(c)(1) and (2) and (h). Also, a member is
not insured under SGLI, and therefore not covered for purposes of
TSGLI, if the member's coverage has terminated under 38 U.S.C.
1968(a)(1)(B) or if the member has forfeited his or her rights to SGLI
under 38 U.S.C. 1973.
Section 1980A(g) of title 38, United States Code, prohibits payment
for a loss resulting from a traumatic injury if the member dies before
the end of the period prescribed by the Secretary of Veterans Affairs
in collaboration with the Secretary of Defense. Pursuant to this
statutory authority, 38 CFR 9.20(d)(3) requires an insured member to
survive for seven days after a traumatic injury to be eligible for
TSGLI benefits for a loss resulting from that traumatic injury. The
seven days (i.e., 168 hours) are measured beginning from the time and
date of the traumatic injury. For example if a member suffers a
traumatic injury at 12 noon Zulu (Greenwich Meridian) time on December
1, 2005, the member must survive until 12 noon Zulu (Greenwich
Meridian) time on December 8, 2005, to be eligible for TSGLI payments.
We selected a seven-day period based on a review of data gathered
by DoD concerning traumatic injuries incurred in Operations Enduring
Freedom and Iraqi Freedom, which shows that it usually takes a minimum
of seven to ten days following a traumatic injury to stabilize the
injured member and transport the member back to the United States for
further treatment and to begin the rehabilitation process. During this
initial period, the service department pays most if not all major
expenses that are incurred by an injured member and/
[[Page 75942]]
or the member's family relating to travel by the family to be at the
member's side, as provided in 37 U.S.C. 411h. As a result, TSGLI
benefits are not needed during the initial period following a traumatic
injury. Once the member's condition is stabilized and doctors and the
member decide on a course of treatment, TSGLI benefits are needed and
will be available to help pay for expenses incurred after the initial
period. Furthermore, if the insured member dies within seven days after
a traumatic injury, although no TSGLI benefit is payable, the basic
SGLI death benefits will be paid to the beneficiary designated by the
member or other eligible beneficiary.
According to 38 U.S.C. 1980A(c)(3), a TSGLI payment may be made
only if a member suffers a scheduled loss before the end of the period
prescribed by the Secretary of Veterans Affairs in collaboration with
the Secretary of Defense, except if the loss is quadriplegia,
paraplegia, or hemiplegia, in which case the member must suffer the
loss not later than 365 days after sustaining the traumatic injury.
Section 9.20(d)(4) of this rule provides that a member must suffer
a scheduled loss within 365 days of the traumatic injury to be eligible
for payment. In determining the appropriate period, we took into
account that DoD has advised that both physicians and service members
do everything possible to save a limb, and as a result, amputation
frequently occurs only after a significant period of time passes after
a traumatic injury. With respect to other types of losses, it is
difficult to determine with any accuracy the time period within which
loss due directly to the traumatic injury can be expected to occur.
Although in some cases, the loss may be expected to occur sooner than
365 days after the traumatic injury, 365 days is similar to the time
frame which Congress has prescribed for severe injuries, such as
quadriplegia and is the broadest period of time included in any
commercial AD&D policy we reviewed. Therefore, Sec. 9.20(d)(4) of this
rule provides that a member must suffer a scheduled loss within 365
days of the traumatic event to be eligible for payment.
Section 1980A(c)(2) of title 38 provides that the TSGLI benefit is
payable only if the scheduled loss ``results directly from [the]
traumatic injury and from no other cause.'' In addition, section
1032(c)(1) of Public Law 109-13 states that TSGLI benefits are payable
for a traumatic injury occurring between October 7, 2001, and December
1, 2005, ``if the qualifying loss was a direct result of injuries
incurred in Operation Enduring Freedom or Operation Iraqi Freedom.'' In
38 CFR 9.20(e)(1), we interpret the phrases ``results directly * * *
and from no other cause'' and ``direct result'' to mean that benefits
are payable for a scheduled loss only if a traumatic injury directly
causes a member's scheduled loss.
Section 1980A(b)(3) of title 38, United States Code, authorizes the
Secretary of Veterans Affairs, in collaboration with the Secretary of
Defense, to promulgate regulations providing the conditions under which
coverage against a scheduled loss will not be provided by TSGLI.
Therefore, Sec. 9.20(e)(2) states that the maximum TSGLI benefit
payable for losses under the schedule in paragraph (e)(7) due to more
than one traumatic event occurring within a seven-day period is
$100,000. We do not believe that Congress intended for a service member
to receive more than the statutory maximum TSGLI benefit of $100,000 as
a result of scheduled losses due to each of several traumatic events
occurring within a short period of time. Also, VA must manage the TSGLI
program ``on the basis of sound actuarial principles.'' Congress has
expressed its understanding that the premium for TSGLI coverage will be
minimal. 151 Cong. Rec. S4095 (2005) (statement of Sen. Craig). In
accordance with that charge, we have concluded that, in the case of
multiple traumatic events occurring within a seven-day period, it is
appropriate to limit recovery to the statutory maximum allowed for a
single traumatic event, regardless of whether the losses come from
multiple traumatic events within a seven-day period. We have concluded
that a period of seven days is appropriate to properly balance the need
for actuarial soundness and the interests of providing adequate
coverage for traumatic events separated by a greater amount of time. A
member could incur a second scheduled loss virtually simultaneously
with the initial scheduled loss. If the benefit for the initial
scheduled loss were for $100,000, we do not believe Congress intended
an additional payment, beyond the maximum provided by law.
If a member loses a limb as a result of a traumatic event, and
within seven days the member sustains another traumatic injury from a
separate traumatic event that results in the loss of sight in both
eyes, the member will receive the benefit under the schedule for those
two losses up to $100,000, the maximum amount payable for a single
traumatic event under the statute. If a member incurs two scheduled
losses separated by more than seven days, the member will receive
payment for both losses according to the schedule. For example, a
member loses a foot, is paid $50,000 according to the schedule, returns
to duty six months later, and sustains the loss of both hands, the
member will be paid an additional $100,000 according to the schedule.
We will calculate the seven-day period beginning with the day on which
the first traumatic event occurs. For example, if there were three
separate traumatic events occurring on day one, day six, and day nine,
a TSGLI benefit will be paid to the member for the scheduled losses
resulting from traumatic events on days one and six, up to $100,000.
Since the event on day nine is outside of the initial seven-day period,
the member would be paid TSGLI according to the schedule for any loss
sustained as a result of the event on day nine.
VA is also promulgating 38 CFR 9.20(e)(3), which explains that
TSGLI benefits are not payable if a service member's loss is due to a
traumatic injury caused by the member's attempted suicide, while sane
or insane, an intentionally self-inflicted injury or an attempt to
inflict such injury, medical or surgical treatment of an illness, or
willful use of an illegal or controlled substance that was not
administered or consumed on the advice of a medical doctor. Also, TSGLI
benefits are not payable for a loss due to a traumatic injury that a
member sustained while committing or attempting to commit a felony.
These limitations follow insurance-industry standards relating to
traumatic injury coverage and are based upon sound actuarial and
financial principles that VA must utilize in administering TSGLI.
As noted, section 1980A(c)(2) of title 38 provides that the TSGLI
benefit is payable only if the scheduled loss ``results directly * * *
and from no other cause.'' Therefore, 38 CFR 9.20(e)(4) of this rule
provides that payment will not be made for a scheduled loss if caused
by a physical or mental illness or disease, except pyogenic infection,
whether or not caused by a traumatic injury, or a mental disorder,
whether or not caused by a traumatic injury. This follows the
commercial AD&D model which excludes losses caused by physical or
mental illness or disease or mental disorders and which contains an
exception for disease resulting from a pyogenic infection, which is
likely to occur as a result of injuries, i.e., wounds, that are
incurred under military conditions.
We have incorporated into 38 CFR 9.20(e)(6) the statutory
definitions in 38 U.S.C. 1980A(b)(2) of quadriplegia, paraplegia, and
hemiplegia because
[[Page 75943]]
these are technical terms with which the public may not be familiar.
Section 1980A(b)(1) and (d)(1) of title 38, United States Code,
authorizes the Secretary of Veterans Affairs, in collaboration with the
Secretary of Defense, to prescribe a schedule of losses resulting from
traumatic injuries for which TSGLI benefits are payable and the amount
that will be paid for each loss that results from the injuries. Section
9.20(e)(7) of title 38, Code of Federal Regulations, contains a
schedule of 43 specific losses for which, if resulting directly from
traumatic injuries, TSGLI is payable and the corresponding amount of
the payment for each loss. In addition, item 44 in the schedule of
losses covers losses due to traumatic injuries other than those
provided for elsewhere in the schedule that directly result in a
member's inability to perform activities of daily living.
Section 1980A(b)(1)(H) requires that the schedule of losses include
coma or the inability to carry out the activities of daily living
resulting from traumatic injury to the brain. A note at the end of the
schedule in Sec. 9.20(e)(7) explains that the period during which a
member is unable to carry out activities of daily living for purposes
of determining the amount of TSGLI benefits to be paid runs from the
day of onset of the member's inability to perform activities of daily
living until the day when the member can again carry out activities of
daily living.
As required by 38 U.S.C. 1980A(d), the amount of the payment in the
schedule at 38 CFR 9.20(e)(7) is based on the severity of the member's
loss. Payments in the schedule range from the statutory minimum of
$25,000 up to the statutory maximum of $100,000. Generally, commercial
AD&D policies pay 100% of the contracted benefit for the loss of two or
more members, e.g., hand, foot, or limb, or for the loss of sight in
both eyes, while paying 50% for loss of one member or loss of sight in
one eye. Based on the commercial AD&D model, the schedule of losses for
TSGLI provides a payment of $100,000 for loss of two or more members,
as well as quadriplegia, hemiplegia, and paraplegia, and $50,000 for
loss of one member or total and permanent loss of sight in one eye.
Although the TSGLI schedule generally follows the commercial AD&D
model, it differs from the basic AD&D model we followed with respect
to:
Permanent and total loss of hearing in one ear.
Combination of losses that include loss of hearing in one
ear.
Combination of losses that include coma.
Combination of losses that include the inability to carry
out the activities of daily living.
Burns greater than second degree, covering 30 percent of
the body or 30 percent of the face.
VA has decided to provide a payment of $25,000 for permanent and
total loss of hearing in one ear and $75,000 for combinations such as
loss of one limb or loss of sight in one eye and total and permanent
loss of hearing in one ear. We note that most of the AD&D policies we
reviewed pay no benefit for total and permanent loss of hearing in one
ear only. However, a few policies do provide a benefit for the total
and permanent loss of hearing in one ear. In those policies, the
benefit payable for total and permanent loss of hearing in one ear is
less than half the benefit for total and permanent loss of hearing in
both ears. We have included the total and permanent loss of hearing in
one ear in the schedule so as to tailor TSGLI to the unique needs of
those injured in military service.
The benefit amounts to be paid for scheduled losses that include
coma or inability to carry out the activities of daily living are based
generally upon the likelihood of recovery as determined by the duration
of the coma or inability to carry out activities of daily living. In
addition, the determination of benefits in this manner is consistent
with commercial insurance industry standards.
In another deviation from commercial industry standards, we provide
in the schedule that burns greater than second degree, covering 30
percent of the body or 30 percent of the face, warrant a payment of
$100,000. The reason for a maximum payment for this type of injury is
due to its severity and length of treatment. Because burns are one of
the most complex and harmful physical injuries, they often require
initial trauma care, followed by careful evaluation and appropriate
wound management. In the case of a 3rd degree or worse burn, skin
grafting or other replacement options are required. When a burn injury
is deep enough to involve muscle, bone, tendon, and/or ligament, it is
often classified as a 4th degree burn. These burns are often life-
threatening in nature, and sometimes require amputation.
In accordance with 38 U.S.C. 1980A(f), Sec. 9.20(f) states that
the uniformed services will determine eligibility for TSGLI. All
uniformed services will certify eligibility based upon section 1032 of
Public Law 109-13 and this rule.
Section 9.20(g) explains how a member initiates a claim for TSGLI
benefits. A member, or someone acting on his or her behalf if he or she
is unable to do so, will obtain a Certification of Traumatic Injury
Protection Form, GL.2005.261, on the VA Insurance website, http://www.insurance.va.gov
, or by contacting the Office of Servicemembers'
Group Life Insurance (OSGLI) at 1-800-419-1473. A member can also
obtain Form GL.2005.261 by contacting his or her branch of service, and
the point of contact for each branch of service is available on the VA
Insurance website or from OSGLI.
The member must complete and sign Part A of Form GL.2005.261, which
requests identifying information. If the member is unable to sign, Form
GL.2005.261 may be signed by the member's guardian or attorney-in-fact.
If a member suffered a scheduled loss as a direct result of the
traumatic injury, survived seven full days from the date of the
traumatic event, and then died before the maximum benefit for which the
service member qualified is paid, the beneficiary or beneficiaries of
the member's SGLI policy may complete Form GL.2005.261.
Section 9.20(g)(2) explains that, if a member seeks traumatic
injury protection benefits for a scheduled loss occurring after
submission of a completed Certification of Traumatic Injury form for a
different scheduled loss, the member must submit a completed Form
GL.2005.261 for the new scheduled loss and for each subsequent
scheduled loss that occurs. For example, if a member seeks traumatic
injury protection benefits for a scheduled loss due to coma from
traumatic injury and/or the inability to carry out activities of daily
living due to traumatic brain injury (Sec. 9.20(e)(7)(xxxvii)), or the
inability to carry out activities of daily living due to loss directly
resulting from a traumatic injury other than an injury to the brain
(Sec. 9.20(e)(7)(xliv)), a completed Form GL.2005.261 must be
submitted for each increment of time for which TSGLI is payable. For
example, if a service member suffers a scheduled loss due to a coma, a
completed Form GL.2005.261 should be filed after the 15th consecutive
day that the member is in the coma, for which $25,000 is payable. If
the member remains in a coma for another 15 days, another completed
Form GL.2005.261 should be submitted and another $25,000 will be paid.
The certification form that has been completed by the service
member, member's guardian or member's attorney-in-fact should then be
sent to
[[Page 75944]]
an attending medical professional for completion of Part B of Form
GL.2005.261 regarding the nature of the member's injury and whether it
meets the schedular requirements of this rule. The appropriate
administrative office of the branch of service will complete Part C of
Form GL.2005.261, certifying that the member was covered under SGLI
when the traumatic injury was sustained and that the member meets the
other eligibility requirements set forth in section 1032 of Public Law
109-13 and this rule. The branch of service will then forward the
completed certification form to the OSGLI for disbursement of the
benefit payment.
Section 9.20(h)(1) states that appeals of TSGLI eligibility
determinations, such as whether the loss occurred within 365 days of
the traumatic injury, whether the injury was self-inflicted, or whether
a loss of hearing was total and permanent, will be made to the
Secretary of the uniformed service that made the determination
regarding the member's eligibility. Points of contact for filing
appeals to the branches of service will be provided on the VA Insurance
website, http://www.insurance.va.gov, and by the Office of
Servicemembers' Group Life Insurance (OSGLI) at 1-800-419-1473.
Section 9.20(h)(2) states that an appeal regarding whether a
service member was covered under SGLI when the traumatic injury was
sustained must be submitted to OSGLI. Appeals regarding actions on the
policy itself, such as whether a service member received a TSGLI
payment, are also directed to OSGLI. Section 9.20(h)(3) provides that a
member is not precluded by anything in this section from pursuing legal
remedies under 38 U.S.C. 1975 and 38 CFR 9.13.
Section 9.20(i) explains to whom the traumatic injury protection
benefit will be paid. The benefit will be paid to the injured member,
except in the following circumstances. If the member is legally
incapacitated, the benefit will be paid to the member's guardian or
attorney-in-fact. If the member dies before a TSGLI payment is made,
the benefit will be paid to the beneficiary designated by the member or
other eligible beneficiary in accordance with 38 U.S.C. 1970(a), which
explains the order of precedence for payment of SGLI proceeds following
an insured's death.
Administrative Procedure Act
In accordance with 5 U.S.C. 553(b)(3)(B), the Secretary of Veterans
Affairs finds that there is good cause to dispense with the opportunity
for prior comment with respect to this rule which explains how the
TSGLI program will be implemented. The Secretary finds that it is
impracticable to delay this regulation for the purpose of soliciting
prior public comment because TSGLI is effective December 1, 2005, and
because service members and their families need the payment provided by
TSGLI as soon as possible following a traumatic injury in order to
reduce the financial burden that results from the severe losses covered
by the schedule. For the foregoing reasons, the Secretary of Veterans
Affairs is issuing this rule as an interim final rule. The Secretary of
Veterans Affairs will consider and address comments that are received
within 30 days of the date this interim final rule is published in the
Federal Register.
Congressional Review Act
Although this rule is a major rule within the meaning of the
Congressional Review Act, 5 U.S.C. 804(2), it will not be subject to
the 60-day delay in effective date applicable to major rules under 5
U.S.C. 801(a)(3) because VA finds that good cause exists under 5 U.S.C.
808(2) to make the rule effective immediately. As stated above,
Congress has directed that TSGLI take effect on December 1, 2005.
Further, service members and their families have an immediate and
urgent need for the payment provided by TSGLI as soon as possible
following a traumatic injury in order to reduce the financial burden
that results form the severe losses covered by the schedule. In
accordance with 5 U.S.C. 801(a)(1), VA will submit to the Comptroller
General and to Congress a copy of this rule and other information,
including VA's economic analysis of this rule as set forth below.
Unfunded Mandates
The Unfunded Mandates Reform Act requires, at 2 U.S.C. 1532, that
agencies prepare an assessment of anticipated costs and benefits before
issuing any rule that may result in an expenditure by State, local, or
tribal governments, in the aggregate, or by the private sector of $100
million or more (adjusted annually for inflation) in any given year.
This rule would have no effect on State, local, or tribal governments.
Paperwork Reduction Act
OMB assigns a control number for each collection of information it
approves. Except for emergency approvals under 44 U.S.C. 3507(j), VA
may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB
control number. The interim final rule at Sec. 9.20 contains
collections of information under the Paperwork Reduction Act (44 U.S.C.
3501-3521) (the Act). Accordingly, under section 3507(d) of the Act, VA
has submitted a copy of this rulemaking action to OMB for its review of
the collections of information. We have requested OMB to approve the
collection of information on an emergency basis by January 23, 2006;
however, we are also requesting comments on the collection of
information provisions contained in Sec. 9.20 on a non-emergency
basis. Comments must be submitted by February 21, 2006.
OMB assigns a control number for each collection of information it
approves. VA may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a
currently valid OMB control number.
Comments on the collections of information should be submitted to
the Office of Management and Budget, Attention: Desk Officer for the
Department of Veterans Affairs, Office of Information and Regulatory
Affairs, Washington, DC 20503, or faxed to 202-395-6974, with copies
mailed or hand-delivered to: Director, Regulations Management (00REG1),
Department of Veterans Affairs, 810 Vermont Ave., NW., Room 1068,
Washington, DC 20420. Comments should indicate that they are submitted
in response to ``RIN 2900-AM36.''
Title: Traumatic Injury Protection (TSGLI) Under The
Servicemembers' Group Life Insurance Program Certification Form and
Instructions.
Summary of collection of information: The interim final rule at
Sec. 9.20(g) contains information for applying for the TSGLI benefit
using the TSGLI Certification Form and for completion of the form by
medical professionals.
Description of the need for information and proposed use of
information: Section 9.20(g)(2) requires that a service member insured
under Servicemembers' Group Life Insurance (SGLI) who wants to be paid
a TSGLI benefit provide certain information to his or her uniformed
service. This information is needed by the uniformed services to
determine eligibility for the TSGLI benefit. Section 9.20(g)(2) also
requires a medical professional to certify that the member has
sustained a traumatic injury that resulted in a scheduled loss. The
information needed is as follows:
Part A: Completed by the Service Member
In Part A, the service member or his or her guardian or attorney-
in-fact needs to provide basic identifying information including: name,
address, telephone
[[Page 75945]]
number, service branch, social security number and date of birth. In
addition, if the member has a guardian or attorney-in-fact who will
receive payment for the benefit on their behalf, the name, address, and
other contact information of the guardian or attorney-in-fact needs to
be provided. The service member also needs to select how they would
like to receive payment (either by Electronic Funds Transfer or through
a checkbook) and provide the appropriate bank information if they elect
Electronic Funds Transfer. Lastly, the service member needs to sign an
authorization for release of medical information to their branch of
service and the Office of Servicemembers' Group Life Insurance (OSGLI).
This release is needed to comply with the Standards for Privacy of
Individually Identifiable Health Information, codified at 45 CFR part
160 and part 164, subparts A and E, so that the service departments and
OSGLI can obtain necessary medical information to determine if the
service member is eligible for the benefit.
Part B: Completed by an Attending Medical Professional
In Part B, an attending medical professional (either military or
civilian) must provide information on the service member's medical
condition. The attending medical professional must indicate in a signed
statement whether the member sustained a traumatic injury or injuries
and a scheduled loss as a direct result of the injury or injuries that
would make the member eligible for the TSGLI benefit.
Part C: Completed by the Branch of Service
In Part C, the service member's branch of service must provide
information on additional eligibility criteria and sign as the
certifying official. The requirements of the Paperwork Reduction Act do
not apply to collections of information from current Government
employees acting within the scope of their duties. 5 CFR 1320.3(c)(4).
Accordingly, the information in Part C of the certification does not
require OMB approval.
Description of likely respondents: Service members, service
members' guardians and attorneys-in-fact, service members'
beneficiaries (if the service member is deceased), and civilian
physicians.
Estimated number of respondents per year: 950.
Estimated frequency of responses per year: 1.
Estimated total annual reporting and recordkeeping burden: 475
hours.
Estimated annual burden per collection: 30 minutes.
The Department considers comments by the public on collections of
information in--
Evaluating whether the collections of information are
necessary for the proper performance of the functions of the
Department, including whether the information will have practical
utility;
Evaluating the accuracy of the Department's estimate of
the burden of the collections of information, including the validity of
the methodology and assumptions used;
Enhancing the quality, usefulness, and clarity of the
information to be collected; and
Minimizing the burden of the collections of information on
those who are to respond, including responses through the use of
appropriate automated, electronic, mechanical, or other technological
collection techniques or other forms of information technology, e.g.,
permitting electronic submission of responses.
OMB is required to make a decision concerning the collections of
information contained in this rule between 30 and 60 days after
publication of this document in the Federal Register. Therefore, a
comment to OMB is best assured of having its full effect if OMB
receives it within 30 days of publication. This does not affect the
deadline for the public to comment on the interim final rule.
Executive Order 12866
This document has been reviewed by the Office of Management and
Budget under Executive Order 12866. Executive Order 12866 directs
agencies to assess all costs and benefits of available regulatory
alternatives and, when regulation is necessary, to select regulatory
approaches that maximize net benefits (including potential economic,
environmental, public health and safety, and other advantages;
distributive impacts; and equity). Executive Order 12866 classifies a
rule as significant if it meets any one of a number of specified
conditions, including having an annual effect on the economy of $100
million, adversely affecting a sector of the economy in a material way,
adversely affecting competition, or adversely affecting jobs. A
regulation is also considered a significant regulatory action if it
raises novel legal or policy issues.
VA estimates that this rule will have an effect $100 million or
greater in any one year under section 3(f)(1) of Executive Order 12866.
Therefore, this rule is a significant regulatory action under Executive
Order 12866.
VA has attempted to follow OMB circular A-4 to the extent feasible
in this analysis. The Circular first calls for a discussion of the need
for the regulation. The SGLI Traumatic Injury benefit is designed to
provide immediate payment to severely injured service members. The
preamble above discusses the need for the regulation in more detail.
The impact of this regulation is primarily to the federal budget,
although service members themselves will eventually be impacted by
changes in the premiums charged for this coverage. A qualifying service
member will receive between $25,000 and $100,000 after suffering a
traumatic injury, depending on the type of loss suffered as a result of
the injury. The premium charged for this coverage is expected to be $1
per month from each service member insured under SGLI. VA continues to
study what premium changes may be needed to cover this benefit;
therefore, a premium of $1 per month, although a reasonable assumption,
may be subject to change in the future. This premium is intended to
cover only the civilian incidence of such injuries. The law provides
that any excess program costs above the premiums collected from service
members will be paid by DoD.
The required funding from DoD is composed of three parts:
retroactive costs, program start-up funds, and prospective monthly
costs. Based upon the information available from DoD, VA has developed
estimates of each of these costs.
By far the largest impact on the budget is due to the retroactive
provision of Public Law 109-13, which provides that any service member
who suffered a qualifying loss between October 7, 2001, and December 1,
2005, will receive a benefit under the TSGLI program if the loss was a
direct result of injuries incurred in Operation Enduring Freedom or
Operation Iraqi Freedom. Based on information from DoD, VA has derived
a preliminary estimate of the retroactive cost in excess of $400
million, based upon over 5000 seriously wounded service members and a
$75,000 average payment amount. Please note that this assumed number of
wounded and payouts is based on preliminary projections; actual payouts
may be significantly higher or lower than this estimated amount. VA
will continue to study the actual demand on the program and will make
adjustments accordingly.
For program startup funds, the law also specifies that the
Secretary of Defense will forward to VA an amount equivalent to half
the anticipated cost of excess claims for the fiscal year on the
December 1st effective date. Since ten
[[Page 75946]]
months will then be left in fiscal year 2006, a five-month advance
payment is required. VA had developed an estimate of $68 million for
the fiscal year 2006 cost to DoD. Using this estimate, the five-month
advance payment due December 1 amounted to $28 million.
In addition, the law provides for the provision of prospective
monthly costs. Specifically, the law provides that the cost of
providing such coverage, less the premiums paid by members, will be
paid by the Secretary of Defense to VA on a monthly basis. Again, using
VA's estimated $68 million cost for fiscal year 2006, monthly payments
of $5.7 million would be required from DoD starting December 2005.
The total of these estimated costs through fiscal year 2006 amounts
to $485 million. VA will continue to develop actuarial models to ensure
that future SGLI premiums fully cover the expected civilian incidence
of such injuries. Due to the unpredictability of traumatic injuries
resulting from military service (including war), VA has not attempted
to estimate the costs to DoD beyond fiscal year 2006. As DoD develops
claim data and becomes more cognizant of the cost of TSGLI, VA will
make appropriate adjustments in the amount of funds requested for
fiscal year 2006. VA requests comment on all of these projections.
Regulatory Flexibility Act
The Secretary of Veterans Affairs hereby certifies that this
interim final rule will not have a significant economic impact on a
substantial number of small entities as they are defined in the
Regulatory Flexibility Act, 5 U.S.C. 601-612. This final rule will not
affect any entity since it does not contain any substantive provisions.
Therefore, pursuant to 5 U.S.C. 605(b), this amendment is exempt from
the initial and final regulatory flexibility analysis requirements of
sections 603 and 604.
The Catalog of Federal Domestic Assistance Program number and
title for this regulation is 64.103, Life Insurance for Veterans.
List of Subjects in Part 9
Life insurance, Military personnel, Veterans.
Approved: December 15, 2005.
R. James Nicholson,
Secretary of Veterans Affairs.
0
For the reasons set out in the preamble, 38 CFR part 9 is amended as
follows:
PART 9--SERVICEMEMBERS' GROUP LIFE INSURANCE AND VETERANS' GROUP
LIFE INSURANCE
0
1. The authority citation for part 9 is revised to read as follows:
Authority: 38 U.S.C. 501, 1965-1980A, unless otherwise noted.
0
2. Section 9.1 is amended by:
0
(a) In paragraph (f), removing ``upon death occurring''.
0
(b) Adding paragraphs (k) through (q).
The addition reads as follows:
Sec. 9.1 Definitions.
* * * * *
(k) The term inability to carry out activities of daily living
means the inability to independently perform at least two of the six
following functions:
(1) Bathing.
(2) Continence.
(3) Dressing.
(4) Eating.
(5) Toileting.
(6) Transferring in or out of a bed or chair with or without
equipment.
(l) The term pyogenic infection means a pus-producting infection.
(m) The term contaminated substance means food or water made unfit
for consumption by humans because of the presence of chemicals,
radioactive elements, bacteria, or organisms.
(n) The term chemical weapon means chemical substances intended to
kill, seriously injure, or incapacitate humans through their
physiological effects.
(o) The term biological weapon means biological agents or
microorganisms intended to kill, seriously injure, or incapacitate
humans through their physiological effects.
(p) The term radiological weapon means radioactive materials or
radiation-producing devices intended to kill, seriously injure, or
incapacitate humans through their physiological effects.
(q) The term attending medical professional means a licensed
physician, optometrist, nurse practitioner, registered nurse, or
physician assistant.
(Authority: 38 U.S.C. 501(a), 1980A)
0
3. Section 9.20 is added to read as follows:
Sec. 9.20 Traumatic injury protection.
(a) What is traumatic injury protection? Traumatic injury
protection provides for the payment of a specified benefit amount to a
member insured by Servicemembers' Group Life Insurance who sustains a
traumatic injury directly resulting in a scheduled loss.
(b) What is a traumatic event? (1) A traumatic event is the
application of external force, violence, chemical, biological, or
radiological weapons, or accidental ingestion of a contaminated
substance causing damage to a living being occurring--
(i) On or after December 1, 2005, or
(ii) On or after October 7, 2001, and through and including
November 30, 2005, if the scheduled loss is a direct result of a
traumatic injury incurred in Operation Enduring Freedom or Operation
Iraqi Freedom.
(2)(i) The term incurred in Operation Enduring Freedom means a
service member was deployed outside of the United States on orders in
support of Operation Enduring Freedom or served in a geographic
location that qualified the service member for the Combat Zone Tax
Exclusion under 26 U.S.C. 211.
(ii) The term incurred in Operation Iraqi Freedom means a service
member was deployed outside of the United States on orders in support
of Operation Iraqi Freedom or served in a geographic location that
qualified the service member for the Combat Zone Tax Exclusion under 26
U.S.C. 211.
(3) A traumatic event does not include a surgical procedure in and
of itself.
(c) What is a traumatic injury? (1) A traumatic injury is physical
damage to a living body that is caused by a traumatic event as defined
in paragraph (b) of this section.
(2) For purposes of this section, the term ``traumatic injury''
does not include damage to a living body caused by--
(i) A mental disorder; or
(ii) 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.
(3) For purposes of this section, all traumatic injuries will be
considered to have occurred at the same time as the traumatic event.
(d) What are the eligibility requirements for payment of traumatic
injury protection benefits? You must meet all of the following
requirements in order to be eligible for traumatic injury protection
benefits.
(1) You must be a member of the uniformed services who is insured
by Servicemembers' Group Life Insurance under section 1967(a)(1)(A)(i),
(B) or (C)(i) of title 38, United States Code, on the date you
sustained a traumatic injury. (For this purpose, you will be considered
a member of the uniformed services until midnight on the date of your
separation from service.)
(2) You must suffer a scheduled loss that is a direct result of a
traumatic injury and no other cause.
[[Page 75947]]
(3) You must survive for a period not less than seven full days
from the date of the traumatic injury. The seven day period begins on
the date and Zulu (Greenwich Meridean) time of the traumatic injury and
ends 168 full hours later.
(4) You must suffer a scheduled loss under paragraph (e)(7) of this
section within 365 days of the traumatic injury.
(e) What is a scheduled loss and what amount will be paid because
of that loss? (1) The term ``scheduled loss'' means a condition listed
in the schedule in paragraph (e)(7) of this section if directly caused
by a traumatic injury. A scheduled loss is payable at the amount
specified in the schedule.
(2) The maximum amount payable under the schedule for all losses
resulting from traumatic events occurring within a seven-day period is
$100,000. We will calculate the seven-day period beginning with the day
on which the first traumatic event occurs.
(3) A benefit will not be paid if a scheduled loss is due to a
traumatic injury--
(i) Caused by--
(A) The member's attempted suicide, while sane or insane;
(B) An intentionally self-inflicted injury or an attempt to inflict
such injury;
(C) Medical or surgical treatment of an illness or disease;
(D) Willful use of an illegal or controlled substance, unless
administered or consumed on the advice of a medical doctor; or
(ii) Sustained while a member was committing or attempting to
commit a felony.
(4) A benefit will not be paid for a scheduled loss resulting
from--
(i) A physical or mental illness or disease, whether or not caused
by a traumatic injury, other than a pyogenic infection or physical
illness or disease caused by biological, chemical, or radiological
weapons or accidental ingestion of a contaminated substance; or
(ii) A mental disorder whether or not caused by a traumatic injury.
(5) Amount Payable under the Schedule of Losses. (i) The maximum
amount payable for all scheduled losses resulting from a single
traumatic event is limited to $100,000. For example, if a traumatic
event on April 1, 2006, results in the immediate total and permanent
loss of sight in both eyes, and the loss of one foot on May 1, 2006, as
a direct result of the same traumatic event, the member will be paid
$100,000.
(ii) If a member suffers more than one scheduled loss as a result
of a single traumatic event, payment will be made for the scheduled
loss with the highest benefit amount.
(iii) If a member suffers more than one scheduled loss from
separate traumatic events occurring more than seven full days apart,
the scheduled losses will be considered separately and a benefit will
be paid for each loss up to the maximum amount according to the
schedule. For example, if a member suffers the loss of one foot at or
above the ankle on May 1, 2006, from one event, the member will be paid
$50,000. If the same member suffers loss of sight in both eyes from an
event that occurred on November 1, 2006, the member will be paid an
additional $100,000.
(6) Definitions. For purposes of this paragraph (e)(6)--
(i) Quadriplegia means the complete and irreversible paralysis of
all four limbs;
(ii) Paraplegia means the complete and irreversible paralysis of
both lower limbs; and
(iii) Hemiplegia means the complete and irreversible paralysis of
the upper and lower limbs on one side of the body.
(7) Schedule of Losses.
------------------------------------------------------------------------
Then the amount that will be
If the loss is-- paid is--
------------------------------------------------------------------------
(i) Total and permanent loss of sight $100,000.
in both eyes.
(ii) Total and permanent loss of $100,000.
hearing in both ears.
(iii) Loss of both hands at or above $100,000.
wrist.
(iv) Loss of both feet at or above $100,000.
ankle.
(v) Quadriplegia....................... $100,000.
(vi) Hemiplegia........................ $100,000.
(vii) Paraplegia....................... $100,000.
(viii) 3rd degree or worse burns, $100,000.
covering 30% of the body or 30% of the
face.
(ix) Loss of one hand at or above wrist $100,000.
and one foot at or above ankle.
(x) Loss of one hand at or above wrist $100,000.
and total and permanent loss of sight
in one eye.
(xi) Loss of one foot at or above ankle $100,000.
and total and permanent loss of sight
in one eye.
(xii) Total and permanent loss of $75,000.
speech and total and permanent loss of
hearing in one ear.
(xiii) Loss of one hand at or above $100,000.
wrist and total and permanent loss of
speech.
(xiv) Loss of one hand at or above $75,000.
wrist and total and permanent loss of
hearing in one ear.
(xv) Loss of one hand at or above wrist $100,000.
and loss of thumb and index finger of
other hand.
(xvi) Loss of one foot at or above $100,000.
ankle and total and permanent loss of
speech.
(xvii) Loss of one foot at or above $75,000.
ankle and total and permanent loss of
hearing in one ear.
(xviii) Loss of one foot at or above $100,000.
ankle and loss of thumb and index
finger of same hand.
(xix) Total and permanent loss of sight $100,000.
in one eye and total and permanent
loss of speech.
(xx) Total and permanent loss of sight $75,000.
in one eye and total and permanent
loss of hearing in one ear.
(xxi) Total and permanent loss of sight $100,000.
in one eye and loss of thumb and index
finger of same hand.
(xxii) Total and permanent loss of $100,000.
thumb of both hands, regardless of the
loss of any other digits.
[[Page 75948]]
(xxiii) Total and permanent loss of $100,000.
speech and loss of thumb and index
finger of same hand.
(xxiv) Total and permanent loss of $75,000.
hearing in one ear and loss of thumb
and index finger of same hand.
(xxv) Loss of one hand at or above $50,000 for of loss of hand
wrist and coma. plus the amount paid for coma
as noted in Item 37 of this
schedule up to a combined
maximum of $100,000.
(xxvi) Loss of one foot at or above $50,000 for loss of foot plus
ankle and coma. the amount paid for coma as
noted in Item 37 of this
schedule up to a combined
maximum of $100,000.
(xxvii) Total and permanent loss of $50,000 for total and permanent
speech and coma. loss of speech plus the amount
paid for coma as noted in Item
37 of this schedule up to a
combined maximum of $100,000.
(xxviii) Total and permanent loss of $50,000 for total and permanent
sight in one eye and coma. loss of sight in one eye plus
the amount paid for coma as
noted in Item 37 of this
schedule up to a combined
maximum of $100,000.
(xxix) Total and permanent loss of $25,000 for total and permanent
hearing in one ear and coma. loss of hearing in one ear
plus the amount paid for coma
as noted in Item 37 of this
schedule up to a combined
maximum of $100,000.
(xxx) Loss of thumb and index finger of $50,000 for loss of thumb and
same hand and coma. index finger of the same hand
plus the amount paid for coma
as noted in Item 37 of this
schedule up to a combined
maximum of $100,000.
(xxxi) Total and permanent loss of $50,000 for loss of sight in
sight in one eye and inability to one eye plus the amount paid
carry out activities of daily living for the inability to carry out
due to traumatic brain injury. activities of daily living due
to traumatic brain injury as
noted in Item 37 of this
schedule up to a combined
maximum of $100,000.
(xxxii) Loss of one hand at or above $50,000 for loss of hand plus
wrist and inability to carry out the amount paid for the
activities of daily living due to inability to carry out
traumatic brain injury. activities of daily living due
to traumatic brain injury as
noted in Item 37 of this
schedule up to a combined
maximum of $100,000.
(xxxiii) Loss of one foot at or above $50,000 for loss of foot plus
ankle and inability to carry out the amount paid for the
activities of daily living due to inability to carry out
traumatic brain injury. activities of daily living due
to traumatic brain injury as
noted in Item 37 of this
schedule up to a combined
maximum of $100,000.
(xxxiv) Loss of thumb and index finger $50,000 for loss of thumb and
of same hand and inability to carry index finger plus the amount
out activities of daily living due to paid for the inability to
traumatic brain injury. carry out activities of daily
living due to traumatic brain
injury as noted in Item 37 of
this schedule up to a combined
maximum of $100,000.
(xxxv) Total and permanent loss of $25,000 for total and permanent
hearing in one ear and inability to loss of hearing in one ear
carry out activities of daily living plus the amount paid for the
due to traumatic brain injury. inability to carry out
activities of daily living due
to traumatic brain injury as
noted in Item 37 of this
schedule up to a combined
maximum of $100,000.
(xxxvi) Total and permanent loss of $50,000 for total and permanent
speech and inability to carry out loss of speech plus the amount
activities of daily living due to paid for the inability to
traumatic brain injury. carry out activities of daily
living due to traumatic brain
injury as noted in Item 37 of
this schedule up to a combined
maximum of $100,000.
(xxxvii) Coma from traumatic injury and/ At 15th consecutive day in a
or the inability to carry out coma, and/or the inability to
activities of daily living due to carry out activities of daily
traumatic brain injury. living--$25,000.
Note 1: Benefits will not be paid under At 30th consecutive day in a
this schedule for concurrent coma, and/or the inability to
conditions of coma and traumatic brain carry out activities of daily
injury.. living--Additional $25,000.
Note 2: Duration of coma includes the At 60th consecutive day in a
day of onset of the coma and the day coma, and/or the inability to
when the member recovers from coma.. carry out activities of daily
Note 3: Duration of the inability to living--Additional $25,000.
carry out activities of daily living At 90th consecutive day in a
due to traumatic brain injury includes coma, and/or the inability to
the day of the onset of the inability carry out activities of daily
to carry out activities of daily living--Additional $25,000.
living and the day the member once (Benefits can be paid for both
again can carry out activities of conditions only if experienced
daily living.. consecutively, not
concurrently.)
(xxxviii) Total and permanent loss of $50,000.
speech.
(xxxix) Loss of one hand at or above $50,000.
wrist.
(xl) Loss of one foot at or above ankle $50,000.
(xli) Total and permanent loss of sight $50,000.
in one eye.
(xlii) Loss of thumb and index finger $50,000.
of same hand.
(xliii) Total and permanent loss of $25,000.
hearing in one ear.
(xliv) The inability to carry out At 30th consecutive day of the
activities of daily living due to loss inability to carry out
directly resulting from a traumatic activities of daily living--
injury other than an injury to the $25,000.
brain. At 60th consecutive day of the
Note: Duration of the inability to inability to carry out
carry out activities of daily living activities of daily living--
includes the day of onset of the Additional $25,000.
inability to carry out activities of At 90th consecutive day of the
daily living and the day when the inability to carry out
member can once again carry out activities of daily living--
activities of daily living.. Additional $25,000.
At 120th consecutive day of the
inability to carry out
activities of daily living--
Additional $25,000.
------------------------------------------------------------------------
(f) Who will determine eligibility for traumatic injury protection
benefits? Each uniformed service will certify the eligibility of its
own members for traumatic injury protection benefits based upon section
1032 of Public Law 109-13 and this section.
(g) How does a member make a claim for traumatic injury protection
benefits? (1)(i) A member who believes he or she qualifies for
traumatic injury protection
[[Page 75949]]
benefits must complete Part A of the Certification of Traumatic Injury
Protection Form and sign the form.
(ii) If a member is unable to do so, anyone acting on the member's
behalf may request a Certification of Traumatic Injury Protection Form
from the uniformed service. However, the Certification of Traumatic
Injury Protection Form must be signed by the member, the member's
guardian, or the member's attorney-in-fact.
(iii) If a member suffered a scheduled loss as a direct result of
the traumatic injury, survived seven full days from the date of the
traumatic event, and then died before the maximum benefit for which the
service member qualifies is paid the beneficiary or beneficiaries of
the member's Servicemembers' Group Life Insurance policy should
complete a Certification of Traumatic Injury Protection Form.
(2) If a member seeks traumatic injury protection benefits for a
scheduled loss occurring after submission of a completed Certification
of Traumatic Injury Protection Form for a different scheduled loss, the
member must submit a completed Certification of Traumatic Injury
Protection Form for the new scheduled loss and for each scheduled loss
that occurs thereafter. For example, if a member seeks traumatic injury
protection benefits for a scheduled loss due to coma from traumatic
injury and/or the inability to carry out activities of daily living due
to traumatic brain injury (Sec. 9.20(e)(7)(xxxvii)), or the inability
to carry out activities of daily living due to loss directly resulting
from a traumatic injury other than an injury to the brain (Sec.
9.20(e)(7)(xliv)), a completed Certification of Traumatic Injury
Protection Form must be submitted for each increment of time for which
TSGLI is payable. Also, for example, if a service member suffers a
scheduled loss due to a coma, a completed Certification of Traumatic
Injury Protection Form should be filed after the 15th consecutive day
that the member is in the coma, for which $25,000 is payable. If the
member remains in a coma for another 15 days, another completed
Certification of Traumatic Injury Protection Form should be submitted
and another $25,000 will be paid.
(h) How does a member or beneficiary appeal an adverse eligibility
determination? (1) Notice of a decision regarding a member's
eligibility for traumatic injury protection benefits will include an
explanation of the procedure for obtaining review of the decision. An
appeal of an eligibility determination, such as whether the loss
occurred within 365 days of the traumatic injury, whether the injury
was self-inflicted or whether a loss of hearing was total and
permanent, must be in writing. An appeal must be submitted by a member
or a member's legal representative or by the beneficiary or the
beneficiary's legal representative, within one year of the date of a
denial of eligibility, to the office of the uniformed service
identified in the decision regarding the member's eligibility for the
benefit.
(2) An appeal regarding whether a member was insured under
Servicemembers' Group Life Insurance when the traumatic injury was
sustained must be in writing. An appeal must be submitted by a member
or a member's legal representative or by the beneficiary or the
beneficiary's legal representative within one year of the date of a
denial of eligibility to the Office of Servicemembers' Group Life
Insurance.
(3) Nothing in this section precludes a member from pursuing legal
remedies under 38 U.S.C. 1975 and 38 CFR 9.13.
(i) Who will be paid the traumatic injury protection benefit? The
injured member who suffered a scheduled loss will be paid the traumatic
injury protection benefit in accordance with title 38 U.S.C. 1980A
except under the following circumstances:
(1) If a member is legally incapacitated, the member's guardian or
attorney-in-fact will be paid the benefit on behalf of the member.
(2) If a member dies before payment is made, the beneficiary or
beneficiaries who will be paid the benefit will be determined in
accordance with 38 U.S.C. 1970(a).
(Authority: 38 U.S.C. 501(a) and 1980A)
[FR Doc. 05-24390 Filed 12-20-05; 10:53 am]
BILLING CODE 8320-01-P
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