Traumatic Injury Servicemembers’ Group Life Insurance (TSGLI)

Traumatic Injury Servicemembers’ Group Life Insurance (TSGLI) NCC Furseth Navy Casualty Assistance Division

Medical/Legal Review • If additional medical review is required • Claim and supporting medical documentation is forwarded to PERS or BUMED for review • If further legal review is required • Claim and supporting documentation is forwarded to NPC for review

Claim Certification • Claim is approved, scanned and forwarded to Office of Servicemembers’ Group Life Insurance (OSGLI) for payment. • Payment is usually issued within 72 hours

Denial Process • Denied claims are scanned by N135C and forwarded to OSGLI • OSGLI notifies the injured Sailor in writing that their claim was denied, the reason for denial, and briefly explains their right to appeal • When a TSGLI claim is denied the injured Sailor can appeal • Appeals of SGLI coverage are made directly to OSGLI, all others to N135C

Appeals • Appeals must contain the following: • Sailor’s identifying information (name, address, and social security number) • Reason the Sailor disagrees with the denial • Support documentation (i.e., medical records, Physical Evaluation Board findings, etc.) • Written comments, documents, records, or any other information which substantiates their claim

Appeals • Decisions that are likely to be appealed: • Sailor’s loss did not qualify under TSGLI • Loss was not a direct result of a traumatic event • Loss was due to a physical or mental illness or a disease not covered under TSGLI • First level appeals will be submitted to N135C for adjudication • Second level appeals will be submitted directly to the Secretary of the Navy Council of Review Boards (CORB)

Common Errors • Claims completed based on interviews with patient and not the result of witnessing the claimed loss or a review of medical documentation • Adding losses to the claim form • If a loss is not on the form it is not covered under TSGLI

Common Errors • Incomplete or missing medical documentation • Incomplete or missing data in Part B of the claim form • Medical documentation does not support loss • Independent Duty Corpsmen cannot sign claim form unless co-signed by a licensed physician

Common Errors • Claim must be signed by a: • Licensed Physician • Optometrist • Nurse Practitioner • Registered Nurse or Physicians Assistant acting within the scope of their practice

Ineligible Claims • PTSD and Depressive Disorders • Sailors are encouraged to seek assistance from the VA • TBI in and of itself • TBI must be associated with a scheduled loss (coma or loss of Activities of Daily Living (ADLs)) • Cognitive Deficits • Must directly lead to losses of ADLs • Other physical or mental illness or a disease not covered under TSGLI • Losses not caused by a traumatic event

Further Information • http://www.npc.navy.mil/CommandSupport/CasualtyAssistance/TSGLI/ • https://www.insurance.va.gov/sgliSite/ TSGLI/TSGLI.htm

Contact Info • NCC Steven Furseth (Program Manager) Steven.j.furseth@navy.mil - 901-874-6801 • HM1 Steven Marsh (Claims Adjudicator) Steven.h.marsh@navy.mil - 901-874-4311

QUESTIONS? The goal of Navy Casualty is to “Lean Toward Yes” while staying within the program guidelines

Traumatic Injury Servicemembers’ Group Life Insurance (TSGLI)