38 C.F.R. § 9.20 Traumatic injury protection.
Title 38 - Pensions, Bonuses, and Veterans' Relief
(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. (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. (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 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 (§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 (§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) [70 FR 75946, Dec. 22, 2005]
Title 38: Pensions, Bonuses, and Veterans' Relief
PART 9—SERVICEMEMBERS' GROUP LIFE INSURANCE AND VETERANS' GROUP LIFE INSURANCE
§ 9.20 Traumatic injury protection.
------------------------------------------------------------------------ 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.(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 dailyNote 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 injury other than an injury to the living_$25,000. brain. At 60th consecutive day of theNote: Duration of the inability to inability to carry out carry out activities of daily living activities of daily includes the day of onset of the living_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 activities of daily living.. living_Additional $25,000. At 120th consecutive day of the inability to carry out activities of daily living_Additional $25,000.------------------------------------------------------------------------
