Traumatic Brain Injury
Better DOD and VA Oversight Can Help Ensure More Accurate, Consistent, and Timely Decisions for the Traumatic Injury Insurance Program Gao ID: GAO-09-108 January 29, 2009In 2005, Congress created a traumatic injury insurance benefit program, known as TSGLI, to help servicemembers with traumatic brain injury and other serious injuries with the financial burdens that they and their families face. The Department of Veterans Affairs (VA) administers the program, in collaboration with the Department of Defense (DOD), while the branches of service are responsible for deciding servicemembers' claims. GAO examined (1) the TSGLI approval rate for traumatic brain injury claimants, and whether DOD and VA have assurance that claims are processed accurately, consistently, and in a timely manner and (2) any challenges servicemembers with traumatic brain injury may have faced in accessing TSGLI benefits, and the extent to which DOD and VA have taken steps to address such challenges. GAO analyzed program data and interviewed DOD and VA officials, servicemembers, and medical professionals.
Although VA data show that 63 percent of servicemembers with traumatic brain injury were approved for TSGLI, the actual approval rate may be lower, and DOD and VA lack assurance that claim decisions are accurate, consistent, and timely within and across the branches of service. VA's data show that 520 of the 821 servicemembers who filed TSGLI claims for traumatic brain injury received benefits. However, the actual approval rate may be lower because VA does not include all denials for traumatic brain injury in its data. In addition, DOD and VA officials told us there is no systematic quality assurance review process to ensure that claim decisions are accurate and consistent within and across the services. Finally, DOD and VA lack reliable data on how long it takes the services to make decisions on traumatic brain injury claims. We identified three major challenges servicemembers with traumatic brain injury have faced and found that DOD and VA have taken a number of steps to address these challenges and expand access to the program. First, while TSGLI is intended as a quick benefit, servicemembers have had difficulties in starting claims soon after their injuries, in part because of a lack of awareness about the program. In response, DOD placed TSGLI staff in 10 of its largest medical treatment facilities to educate servicemembers and help them file claims. Second, the eligibility criteria for traumatic brain injury in place at the time of our review were subjective and unclear, which created some challenges for servicemembers. The criteria stated that a servicemember with traumatic brain injury must be completely dependent on another person to perform two of six activities of daily living, such as eating or getting dressed. However, medical providers may have differing opinions on whether someone who requires verbal instructions or reminders to perform these activities is considered completely dependent. VA has since clarified that a servicemember who requires verbal assistance is eligible, but acknowledged that subjectivity still exists in assessing functional ability. Third, servicemembers with traumatic brain injury have faced challenges in obtaining medical records to prove that they meet eligibility criteria. VA made a change to the program to allow servicemembers who can document a 15-day hospital stay to be eligible for a minimum benefit. DOD and VA are reviewing all claims that were denied or approved for less than the maximum amount to determine whether servicemembers are now eligible under these changes.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-09-108, Traumatic Brain Injury: Better DOD and VA Oversight Can Help Ensure More Accurate, Consistent, and Timely Decisions for the Traumatic Injury Insurance Program
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Traumatic Injury Insurance Program' which was released on January 29,
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Report to the Ranking Member, Committee on Oversight and Government
Reform, House of Representatives:
United States Government Accountability Office:
GAO:
January 2009:
Traumatic Brain Injury:
Better DOD and VA Oversight Can Help Ensure More Accurate, Consistent,
and Timely Decisions for the Traumatic Injury Insurance Program:
GAO-09-108:
GAO Highlights:
Highlights of GAO-09-108, a report to the Ranking Member, Committee on
Oversight and Government Reform, House of Representatives.
Why GAO Did This Study:
In 2005, Congress created a traumatic injury insurance benefit program,
known as TSGLI, to help servicemembers with traumatic brain injury and
other serious injuries with the financial burdens that they and their
families face. The Department of Veterans Affairs (VA) administers the
program, in collaboration with the Department of Defense (DOD), while
the branches of service are responsible for deciding servicemembers‘
claims. GAO examined (1) the TSGLI approval rate for traumatic brain
injury claimants, and whether DOD and VA have assurance that claims are
processed accurately, consistently, and in a timely manner and (2) any
challenges servicemembers with traumatic brain injury may have faced in
accessing TSGLI benefits, and the extent to which DOD and VA have taken
steps to address such challenges. GAO analyzed program data and
interviewed DOD and VA officials, servicemembers, and medical
professionals.
What GAO Found:
Although VA data show that 63 percent of servicemembers with traumatic
brain injury were approved for TSGLI, the actual approval rate may be
lower, and DOD and VA lack assurance that claim decisions are accurate,
consistent, and timely within and across the branches of service. VA‘s
data show that 520 of the 821 servicemembers who filed TSGLI claims for
traumatic brain injury received benefits. However, the actual approval
rate may be lower because VA does not include all denials for traumatic
brain injury in its data. In addition, DOD and VA officials told us
there is no systematic quality assurance review process to ensure that
claim decisions are accurate and consistent within and across the
services. Finally, DOD and VA lack reliable data on how long it takes
the services to make decisions on traumatic brain injury claims.
We identified three major challenges servicemembers with traumatic
brain injury have faced and found that DOD and VA have taken a number
of steps to address these challenges and expand access to the program.
First, while TSGLI is intended as a quick benefit, servicemembers have
had difficulties in starting claims soon after their injuries, in part
because of a lack of awareness about the program. In response, DOD
placed TSGLI staff in 10 of its largest medical treatment facilities to
educate servicemembers and help them file claims. Second, the
eligibility criteria for traumatic brain injury in place at the time of
our review were subjective and unclear, which created some challenges
for servicemembers. The criteria stated that a servicemember with
traumatic brain injury must be completely dependent on another person
to perform two of six activities of daily living, such as eating or
getting dressed. However, medical providers may have differing opinions
on whether someone who requires verbal instructions or reminders to
perform these activities is considered completely dependent. VA has
since clarified that a servicemember who requires verbal assistance is
eligible, but acknowledged that subjectivity still exists in assessing
functional ability. Third, servicemembers with traumatic brain injury
have faced challenges in obtaining medical records to prove that they
meet eligibility criteria. VA made a change to the program to allow
servicemembers who can document a 15-day hospital stay to be eligible
for a minimum benefit. DOD and VA are reviewing all claims that were
denied or approved for less than the maximum amount to determine
whether servicemembers are now eligible under these changes.
Figure: TSGLI Activities of Daily Living Eligibility Criteria for
Traumatic Brain Injury:
[Refer to PDF for image]
This figure is an illustration of TSGLI Activities of Daily Living
Eligibility Criteria for Traumatic Brain Injury, as follows:
Activities of daily living: Bathing( Tub, sponge bath, or shower);
Servicemember is unable to perform the activity if he or she: Needs
assistance in bathing or cannot bathe.
Activities of daily living: Continence; Servicemember is unable to
perform the activity if he or she: Is unable to manage and control
bowel and bladder functions.
Activities of daily living: Dressing;
Servicemember is unable to perform the activity if he or she: Needs
assistance in getting dressed.
Activities of daily living: Eating;
Servicemember is unable to perform the activity if he or she: Needs
assistance in eating or is fed intravenously or by feeding tube.
Activities of daily living: Toileting; Servicemember is unable to
perform the activity if he or she: Needs assistance to go to and from
toilet to relieve bladder or bowel or to perform associated personal
hygiene.
Activities of daily living: Transferring; Servicemember is unable to
perform the activity if he or she: Needs assistance to get in and out
of bed or a chair.
Sources: GAO analysis of the Department of Veterans Affairs‘ TSGLI
procedural guide (August 2007); Art Explosion (images).
[End of figure]
What GAO Recommends:
GAO recommends that DOD and VA (1) implement a quality assurance review
process to help ensure that decisions are accurate and consistent
within and across the services and (2) take steps to ensure the data
required to assess the approval rate for traumatic brain injury and
timeliness of the claims process are reliable and comprehensive. DOD
and VA generally agreed with our recommendations.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-09-108]. For more
information, contact Daniel Bertoni at (202) 512-7215 or
bertonid@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Traumatic Brain Injury Approval Rates May Be Lower Than 63 Percent, and
DOD and VA Lack Assurance That TSGLI Decisions Are Accurate,
Consistent, and Timely within and across the Services:
Servicemembers with Traumatic Brain Injury Have Faced Challenges in
Initiating Claims and Proving Eligibility for TSGLI Benefits, and DOD
and VA Have Taken Steps to Address These Challenges:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: GAO Contact and Staff Acknowledgments:
Table:
Table 1: TSGLI Schedule of Losses:
Figures:
Figure 1: Description of Activities of Daily Living Criteria for TSGLI:
Figure 2: Key Steps in the TSGLI Claims Process:
Figure 3: Traumatic Brain Injury Claims Not Included in VA's Approval
Rate Data:
Figure 4: VA Study on Average Timeliness of Key Steps in the Claims
Process from December 1, 2005, to December 31, 2006:
Figure 5: Comparison of the Previous and Revised TSGLI Claim Forms for
One Activity of Daily Living:
Abbreviations:
DOD: Department of Defense:
OSGLI: Office of Servicemembers' Group Life Insurance:
OTI: other traumatic injury:
TBI: traumatic brain injury:
TSGLI: Servicemembers' Group Life Insurance Traumatic Injury Protection
Program:
VA: Department of Veterans Affairs:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
January 29, 2009:
The Honorable Darrell Issa:
Ranking Member:
Committee on Oversight and Government Reform:
House of Representatives:
Dear Mr. Issa:
Traumatic brain injury is one of the most common wounds of the current
military operations in Afghanistan and Iraq. The nature of these
conflicts--in particular, the widespread use of improvised explosive
devices--increases the likelihood that servicemembers will be exposed
to incidents such as blasts that can cause a traumatic brain injury,
which is defined as an injury caused by a blow or jolt to the head or a
penetrating head injury that disrupts the normal function of the brain.
In 2008, the RAND Corporation estimated that about 20 percent, or
320,000, of U.S. servicemembers returning from Afghanistan and Iraq
suffered some type of traumatic brain injury during their deployment.
[Footnote 1]
The number of these and other traumatic injuries suffered by
servicemembers in the current conflicts led Congress to create the
Servicemembers' Group Life Insurance Traumatic Injury Protection
Program, known as TSGLI, in 2005. TSGLI is intended to provide a quick
lump sum payment to help address the financial burdens that
servicemembers and their families face as a result of their injury.
Benefits are intended to meet servicemembers' needs after their
injuries but before they start receiving veterans' benefits. For
example, the benefits may enable a spouse to leave his or her job and
relocate to be with the injured servicemember during treatment and
rehabilitation. TSGLI is an insurance benefit attached as a rider to
the existing Servicemembers' Group Life Insurance program. The program
is modeled after commercial accidental death and dismemberment policies
and covers injuries such as loss of hearing or vision or loss of a
limb. However, TSGLI differs from many commercial policies in that it
is tailored to meet the needs of servicemembers by including injuries
such as traumatic brain injury. TSGLI benefits range from $25,000 to
$100,000, depending on the type and nature of the traumatic injury. As
of June 2008, the program had awarded more than $285 million to over
4,600 injured servicemembers. The Department of Veterans Affairs (VA)
is responsible for administering the TSGLI program, in collaboration
with the Department of Defense (DOD), while the individual branches of
service are responsible for deciding servicemembers' claims.
Questions have been raised about whether servicemembers with traumatic
brain injury have faced challenges in accessing benefits, given that
their injuries--which may result in more cognitive than physical
impairments--may be more difficult to substantiate than other traumatic
injuries, such as amputations. To be eligible for benefits,
servicemembers with traumatic brain injury must demonstrate that they
were unable to perform two of six activities of daily living, such as
bathing or eating, for at least 15 consecutive days because of their
injury.
At your request, we reviewed TSGLI as it relates to servicemembers with
traumatic brain injury. Specifically, we examined (1) the approval rate
of TSGLI claims for traumatic brain injury, and whether DOD and VA have
assurance that claims are processed accurately, consistently, and in a
timely manner and (2) any challenges servicemembers with traumatic
brain injury may have faced in accessing TSGLI benefits, and the extent
to which DOD and VA have taken steps to address such challenges.
To develop the information for this report, we analyzed data VA
gathered from its contractor, the Office of Servicemembers' Group Life
Insurance, and the services on the number of claimants and the final
disposition and timeliness of their claims since the program's
inception. We also reviewed TSGLI enacting legislation, VA and service
branch implementing regulations and guidance, and VA's year-one review
of the program. We interviewed officials from VA, the Office of
Servicemembers' Group Life Insurance, and the services about procedures
for verifying their data. In addition, we pulled a random sample of 100
claimants' claim forms from VA's contractor's central database of 8,205
claimants, as of June 30, 2008, to assess the reliability of these
data. We found the data were sufficiently reliable to report the total
number of claimants and the final disposition of their claims, but we
identified a key data limitation for reporting approval rates for
traumatic brain injury. We also found the data on the timeliness of
some key steps in the claims process to be unreliable. Furthermore, we
explored the procedures that VA, its contractor, and the services have
in place to ensure accuracy and consistency of decision making.
[Footnote 2] We discussed challenges that servicemembers with traumatic
brain injury have faced with DOD and VA officials; service branch TSGLI
processing office officials; medical professionals, including officials
from the Defense and Veterans Brain Injury Center and the Brain Injury
Association of America; and military and veterans' advocacy groups. We
also discussed such challenges with servicemembers and some family
members in group settings and individual interviews, medical providers,
and service branch TSGLI staff at Brooke Army Medical Center, Fort Sam
Houston, Texas; National Naval Medical Center, Bethesda, Maryland;
Walter Reed Army Medical Center, Washington, D.C.; and the Polytrauma
Rehabilitation Center at the Hunter Holmes McGuire VA Medical Center,
Richmond, Virginia. We selected these sites because they represent
three of DOD's larger medical treatment facilities for servicemembers
with traumatic brain injury and one of VA's four designated traumatic
brain injury centers. In addition, we conducted telephone interviews
with randomly selected servicemembers with traumatic brain injury who
have applied for TSGLI and some of their family members. Furthermore,
we reviewed data from a customer satisfaction survey of servicemembers
who applied for TSGLI benefits, conducted by VA's contractor, and found
these data to be reliable for our purposes. See appendix I for a more
detailed description of our scope and methodology.
We conducted this performance audit from January 2008 through January
2009 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit
to obtain sufficient, appropriate evidence to provide a reasonable
basis for our findings and conclusions based on our audit objectives.
We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.
Results in Brief:
Although VA data show that 63 percent of servicemembers with traumatic
brain injury were approved for TSGLI, the actual approval rate may be
lower, and DOD and VA lack assurance that claim decisions are accurate,
consistent, and timely within and across the services. According to VA
data, 520 of the 821 servicemembers claiming a loss due to traumatic
brain injury were approved, as of June 2008. However, the actual
approval rate may be lower because VA's data do not include all denials
for traumatic brain injury. We also found that there is no systematic
quality assurance review process to ensure that claim decisions are
accurate and consistent within and across the services, a key internal
control activity and a component of other VA benefits programs. In
addition, DOD and VA lack reliable, sufficient data for overseeing
TSGLI claims. VA's central database does not capture all key aspects of
the claims process, such as the time that it takes the services to make
a decision on a claim. VA officials recognized this limitation and
began collecting separate timeliness data from the services on a
regular basis in 2007. However, the data they have collected since then
are unreliable. For example, about one-third of the data on claim
processing times that VA provided to us had dates that were missing or
out of sequence. Furthermore, the data VA collects from the services do
not break out claims by injury. As a result, DOD and VA lack
information on how long it takes the services to make decisions on
traumatic brain injury claims.
We identified three major challenges that servicemembers with traumatic
brain injury have faced--initiating claims, proving that they met
eligibility criteria, and providing adequate documentation to support
their claims--and DOD and VA have taken a number of steps to address
these challenges and expand access to the program for more
servicemembers with traumatic brain injury. First, while TSGLI is
intended as a quick benefit, servicemembers, including those with
traumatic brain injury, have had difficulties in starting claims soon
after their injuries. For example, some servicemembers we interviewed
reported that they did not apply immediately due to the severity of
their injuries or a lack of awareness of the program. In response, DOD
placed TSGLI staff in 10 of its largest medical treatment facilities to
educate servicemembers about the program and help them navigate the
claims process. Second, the eligibility criteria in place at the time
of our review for loss of activities of daily living were subjective
and unclear, which created challenges for servicemembers with traumatic
brain injury in proving that they met the criteria. For example, the
criteria stated that a servicemember with traumatic brain injury must
be completely dependent on another person to qualify for benefits.
However, medical providers may have differing opinions on whether a
servicemember with a traumatic brain injury who requires verbal
assistance to perform the activities of daily living, such as
instructions on how to dress, is considered completely dependent.
During the course of our review, VA completed a comprehensive year-one
review of the TSGLI program and made changes to the TSGLI claim form
and guidance to clarify that a servicemember who requires verbal
assistance is eligible. Third, servicemembers with traumatic brain
injury have faced challenges in proving they met the eligibility
criteria because they lacked medical documentation with sufficient
information on the length of time they were unable to perform
activities of daily living. To remedy this problem, VA made a change to
the program to allow servicemembers who can document a 15-day hospital
stay to be eligible for the minimum benefit of $25,000. This change
will expand access to the program for more servicemembers with
traumatic brain injury as well as those with other traumatic injuries.
DOD and VA officials told us they are reviewing all claims that were
denied or approved for less than the maximum amount to determine
whether the servicemembers are now eligible for an initial or higher
TSGLI payment under the clarified guidance for the activities of daily
living criteria and the new 15-day hospital stay criterion.
We are making two recommendations to improve management of the TSGLI
program and provide greater assurance that injured servicemembers
receive accurate, consistent, and timely treatment. We are recommending
that the Secretary of Veterans Affairs work with the Secretary of
Defense and the branches of service to implement a systematic quality
assurance review process to help ensure that TSGLI benefit decisions
are accurate and consistent within and across the services. We are also
recommending that the agencies work together to take steps to ensure
that the data required to assess approval rates for traumatic brain
injury and the timeliness of key steps in the TSGLI claims process are
reliable and comprehensive.
We provided a draft of this report to the Department of Defense; the
Department of Veterans Affairs; and VA's contractor, the Office of
Servicemembers' Group Life Insurance. DOD and VA provided written
comments, shown in appendixes II and III, respectively, and VA also
provided technical comments, that we have incorporated into the report
as appropriate. The Office of Servicemembers' Group Life Insurance
provided oral comments, and we have incorporated them into the report
as appropriate. The agencies and the Office of Servicemembers' Group
Life Insurance generally agreed with our recommendations.
Background:
Traumatic brain injury can vary greatly in terms of severity--from mild
cases that might involve a brief change in mental status, such as being
dazed or confused, to severe cases that may involve an extended period
of unconsciousness or amnesia after the injury. The Defense and
Veterans Brain Injury Center classifies brain injuries as mild,
moderate, or severe based on factors associated with the initial
injury, such as the length of time in a coma, rather than on the
symptoms or long-term effects. Servicemembers who sustain even a mild
traumatic brain injury may experience short-term physical symptoms such
as headaches or dizziness, emotional symptoms such as anxiety or
irritability, or cognitive impairments such as difficulty concentrating
or sleep disturbances. According to the Defense and Veterans Brain
Injury Center, civilian research on brain injury shows that the
majority of people with mild traumatic brain injury recover within a
few months or a year, but some may experience symptoms related to mild
traumatic brain injury months or even years after their injury.
[Footnote 3] Servicemembers also may have other physical injuries in
addition to a traumatic brain injury or may suffer from the cumulative
effects of multiple blasts that can slow or complicate their recovery.
Furthermore, some of the symptoms of mild traumatic brain injury--such
as irritability and insomnia--are similar to those associated with
other conditions, such as post-traumatic stress disorder.
Although understanding of traumatic brain injury has increased among
the medical community in recent decades, according to a DOD task force
on traumatic brain injury, gaps remain in research on the short-and
long-term effects of traumatic brain injury. DOD is currently investing
$300 million in more than 170 research grants to study traumatic brain
injury and post-traumatic stress disorder. According to DOD, funds will
be used to improve the prevention and treatment of traumatic brain
injury and improve the quality of life for people suffering from
traumatic brain injury.
While the medical community has established mild, moderate, and severe
classifications based on the initial characteristics of traumatic brain
injuries, the legislation creating the TSGLI program did not base
eligibility on these classifications.[Footnote 4] Rather, it based
eligibility on brain injuries that result in a loss of functioning,
specifically the ability to perform two of six activities of daily
living. According to VA, the activities of daily living criteria are
used by some commercial insurance industry carriers in their disability
and long-term care policies. The activities of daily living are (1)
bathing, (2) continence, (3) dressing, (4) eating, (5) toileting, and
(6) transferring in and out of bed or a chair. See figure 1 for a
description of these activities.
Figure 1: Description of Activities of Daily Living Criteria for TSGLI:
[Refer to PDF for image]
This figure is an illustration of TSGLI Activities of Daily Living
Eligibility Criteria for Traumatic Brain Injury, as follows:
Activities of daily living: Bathing( Tub, sponge bath, or shower);
Servicemember is unable to perform the activity if he or she: Needs
assistance in bathing or cannot bathe.
Activities of daily living: Continence; Servicemember is unable to
perform the activity if he or she: Is unable to manage and control
bowel and bladder functions.
Activities of daily living: Dressing;
Servicemember is unable to perform the activity if he or she: Needs
assistance in getting dressed.
Activities of daily living: Eating;
Servicemember is unable to perform the activity if he or she: Needs
assistance in eating or is fed intravenously or by feeding tube.
Activities of daily living: Toileting; Servicemember is unable to
perform the activity if he or she: Needs assistance to go to and from
toilet to relieve bladder or bowel or to perform associated personal
hygiene.
Activities of daily living: Transferring; Servicemember is unable to
perform the activity if he or she: Needs assistance to get in and out
of bed or a chair.
Sources: GAO analysis of the Department of Veterans Affairs‘ TSGLI
procedural guide (August 2007); Art Explosion (images).
[End of figure]
In May 2005, Congress created the TSGLI program to provide lump sum
payments to traumatically injured servicemembers. According to VA,
these payments are intended to provide a short-term benefit during a
servicemember's recovery period, whereas the VA disability compensation
program is designed to meet the long-term financial needs of
servicemembers who lose income-earning potential due to their injuries.
The law mandated coverage of certain specific losses, including coma or
the inability to perform two of the activities of daily living
resulting from traumatic injury to the brain. The law also gave VA the
authority to prescribe additional injuries not specifically listed in
the law. VA included additional losses by creating an "other traumatic
injury" category to cover traumatic injuries that were not specified in
the statute. For example, a gunshot wound to the torso could result in
multiple injuries that, while not specifically listed in the law, are
significant. As with traumatic brain injury, a servicemember must be
unable to perform two of six activities of daily living to qualify for
benefits under the other traumatic injury category. However, where
servicemembers with traumatic brain injury must be unable to perform
activities of daily living for at least 15 days to receive a TSGLI
benefit, the minimum threshold for servicemembers applying under the
other traumatic injury category is 30 days.
Servicemembers who are injured on or after December 1, 2005, the
effective date of the program, are eligible to file a claim for a
traumatic injury sustained anywhere.[Footnote 5] Servicemembers injured
in a combat zone prior to this date but on or after October 7, 2001--
the date military operations in Afghanistan began--are eligible to file
a retroactive claim.[Footnote 6] In 2008, legislation passed the Senate
that included a provision that would eliminate the requirement that the
traumatic injury be incurred in a combat zone to be eligible for
retroactive benefits. That provision was not included in the bill
passed by the House of Representatives in September 2008. The
Congressional Budget Office estimated that expanding retroactive
criteria would make an estimated 700 servicemembers eligible for
benefits totaling $47 million.
To qualify for a TSGLI payment:
1. The servicemember's qualifying injury or loss[Footnote 7] must be
directly caused by a traumatic event.
2. The traumatic event must occur before midnight on the day that the
member separates from the uniformed services.
3. The servicemember's qualifying injury or loss must occur within 730
days (2 years) of the traumatic event.
4. The servicemember must survive for at least 7 days from the date of
the traumatic injury.[Footnote 8]
5. The injury cannot be caused by a mental disorder, mental or physical
illness or disease, among other exceptions.[Footnote 9]
TSGLI provides payments ranging from $25,000 to $100,000, depending on
the type and nature of the injury. Servicemembers may be eligible to be
paid for injuries under two or more categories, but they may not
receive more than a total of $100,000 for injuries resulting from one
traumatic event.[Footnote 10] See table 1 for the losses covered by
TSGLI at the time of our review.
Table 1: TSGLI Schedule of Losses:
Qualifying losses: Amputation (loss of foot, hand, or thumb and index
finger on the same hand);
TSGLI benefits: $50,000 (or $100,000 for both feet or hands).
Qualifying losses: Total and permanent loss of speech;
TSGLI benefits: $50,000.
Qualifying losses: Total and permanent loss of sight in one eye;
TSGLI benefits: $50,000 (or $100,000 for both eyes).
Qualifying losses: Total and permanent loss of hearing in one ear;
TSGLI benefits: $25,000 (or $100,000 for both ears).
Qualifying losses: Paralysis (quadriplegia, paraplegia, and
hemiplegia);
TSGLI benefits: $100,000.
Qualifying losses: Burns (third-degree burn to at least 30 percent of
face or 30 percent of body);
TSGLI benefits: $100,000.
Qualifying losses: Coma (for at least 15, 30, 60, or 90 days);
TSGLI benefits: $25,000 for 15 consecutive days up to $100,000 for 90
days.
Qualifying losses: Traumatic brain injury resulting in loss of
activities of daily living (for at least 15, 30, 60, or 90 days);
TSGLI benefits: $25,000 for 15 days up to $100,000 for 90 days.
Qualifying losses: Other traumatic injuries resulting in loss of
activities of daily living (for at least 30, 60, 90, or 120 days);
TSGLI benefits: $25,000 for 30 days up to $100,000 for 120 days.
Source: GAO analysis of the Department of Veterans Affairs' TSGLI
procedural guide (August 2007).
Note: On November 26, 2008, VA published interim final regulations that
modified the schedule of losses. Among other changes, VA added a
$25,000 TSGLI benefit for a 15-day continuous hospital stay due to
traumatic brain injury or other traumatic injuries.
[End of table]
VA's Insurance Service is responsible for administering the TSGLI
program, setting policies and issuing regulations, in collaboration
with DOD.[Footnote 11] According to agency officials, one way that DOD
and VA regularly coordinate is through monthly conference calls to
discuss issues related to program administration.[Footnote 12] VA is
responsible for ensuring the financial health of the program, and DOD
collects TSGLI premiums--currently $1 per month for servicemembers with
full-time coverage through the Servicemembers' Group Life Insurance
program--and forwards them monthly to VA for transfer to the Office of
Servicemembers' Group Life Insurance. DOD, through the branches of
service, is responsible for covering costs that exceed premium income
due to the extra hazards of military service. The services are
responsible for developing and deciding servicemembers' claims as well
as overseeing reconsiderations and appeals.
The Office of Servicemembers' Group Life Insurance--an office
established by a contractor, the commercial life insurance company
Prudential--is responsible for paying benefits to servicemembers who
are approved and for issuing denial letters to those who are not
approved. The Office of Servicemembers' Group Life Insurance is also
responsible for centrally recording data on all TSGLI claims, including
reconsiderations and appeals. If a servicemember is not satisfied with
the decision, he or she may submit additional medical documentation and
request that the claim be reconsidered by the TSGLI office within their
branch of service. If still not satisfied with the results of the
reconsideration, the servicemember can appeal the decision to a branch
of service appeals body. See figure 2 for an illustration of the key
steps in the TSGLI claims process.
Figure 2: Key Steps in the TSGLI Claims Process:
[Refer to PDF for image]
This figure is an illustration of the key steps in the TSGLI claims
process, as follows:
1) Traumatic event occurs: Defined by VA as ’application of external
force, violence, chemical, biological, or radiological weapons, or
accidental ingestion of a contaminated substance causing damage to a
living body.“
2) Date of qualified loss: The date the servicemember has a loss that
makes him or her eligible for the program.
3) Medical provider signs claim form: Medical provider indicates the
servicemember‘s injuries and ability to perform activities of daily
living on the TSGLI claim form.
4) Service-member submits TSGLI claim form to the branch of service.
5) Service certifies claim: Branch of service receives claim form and
either (1) approves or (2) denies the claim.
6) Office of Service-members‘ Group Life Insurance (OSGLI) receives
claim: OSGLI receives decision and either (1) pays claim or (2) issues
denial letter.
7) Reconsideration and appeals process: Each branch of service has its
own appeals process. Generally, the servicemember can first request a
reconsideration from the branch of service‘s TSGLI office and then
appeal to the branch of service appeals body. Finally, servicemembers
have the right to file suit in federal court.
Sources: GAO analysis of the Department of Veterans Affairs‘ TSGLI
procedural guide (August 2007); Art Explosion (images).
[End of figure]
Traumatic Brain Injury Approval Rates May Be Lower Than 63 Percent, and
DOD and VA Lack Assurance That TSGLI Decisions Are Accurate,
Consistent, and Timely within and across the Services:
Although VA data show that 63 percent of servicemembers claiming a
traumatic brain injury were approved for TSGLI, the actual approval
rate may be lower; and DOD and VA lack assurance that claim decisions
are accurate, consistent, and timely within and across the services.
The actual approval rate for traumatic brain injury claimants may be
lower because VA's data do not include all traumatic brain injury
denials. In addition, neither DOD nor VA has a systematic quality
assurance review process to ensure that claim decisions are accurate
and consistent within and across the services, a key internal control
activity and a component of other VA benefits programs. Finally, DOD
and VA lack reliable, sufficient data on the timeliness of key steps in
the claims process, particularly data on how long servicemembers with
traumatic brain injury wait for their benefits after they submit their
TSGLI applications.
VA Data Show 63 Percent of Servicemembers Claiming a Traumatic Brain
Injury Were Approved, but the Actual Approval Rate May Be Lower:
VA's data show that 63 percent of servicemembers who filed a TSGLI
claim for traumatic brain injury were approved, but the actual approval
rate may be lower because of the way that VA tracks its data. According
to VA's data, 821 servicemembers applied for TSGLI benefits for a loss
due to traumatic brain injury and 520 (63 percent) were approved, which
is higher than the overall TSGLI approval rate of 56 percent. However,
these data do not include all traumatic brain injury denials and, as a
result, the actual approval rate may be lower.
Officials from VA and the contractor that administers the program--the
Office of Servicemembers Group Life Insurance--told us that they do not
include traumatic brain injury claims where, according to the medical
provider who signed the claim form, the servicemember did not suffer a
loss in his or her ability to perform activities of daily living due to
traumatic brain injury. Officials explained that they do not include
these claims in their data due to a software limitation--their system
will not allow claims to be recorded in the traumatic brain injury
category unless the medical provider indicated a loss in at least one
of the six activities of daily living. To record these denied claims,
VA places them in the other traumatic injury category. We were unable
to determine how many denials were not included in the traumatic brain
injury category in VA's data, but we found 4 such denials in our random
sample of 100 claims.[Footnote 13] See figure 3 for an illustration of
traumatic brain injury claims that were not included in VA's data.
Figure 3: Traumatic Brain Injury Claims Not Included in VA's Approval
Rate Data:
[Refer to PDF for image]
This figure is a vertical bar graph depicting the following data:
Traumatic Brain Injury Claims Not Included in VA's Approval Rate Data:
Traumatic brain injury claimants who were included in VA‘s data,
Approved: 520.
Traumatic brain injury claimants who were included in VA‘s data,
Denied: 301.
Denied traumatic brain injury claimants who were not included in VA‘s
data: Unknown number.
Source: GAO analysis of Department of Veterans Affairs data.
[End of figure]
Finally, the approval rates in VA's data reflect final approval rates
because they also include claimants who were initially denied, but who
were approved on reconsideration or appeal.[Footnote 14] If a
servicemember is dissatisfied with the initial decision, he or she can
request a reconsideration--a review of the denial or request for a
higher benefit award based on new medical documentation--or an appeal.
About 40 percent of the requests for a review of the initial decision
were eventually approved or awarded a higher amount.
However, VA could not provide much detail on why claims for traumatic
brain injury were denied or why decisions were changed upon
reconsideration or appeal. Adjudicators in the services describe why
they are denying a claim on the claim form, but VA's contractor groups
these reasons into broad categories in VA's data system, such as
"provisions not met." As a result, VA has little information across the
services on the specific reasons that claims were denied.[Footnote 15]
VA's data also only has a few broad categories to capture the reasons
that initial decisions were upheld or reversed. VA officials told us
they are improving the level of detail their data will include on the
reasons that claims are denied.
DOD and VA Lack Assurance That TSGLI Decisions Are Accurate and
Consistent within and across the Services:
Neither DOD nor VA has a systematic quality assurance review process to
ensure that claim decisions are accurate and consistent within and
across the services. A quality assurance review process is a key
internal control activity to ensure proper stewardship of federal
resources and a component of other VA benefits programs.[Footnote 16]
For example, VA has a quality assurance review process for its
disability compensation program, known as the Systematic Technical
Accuracy Review, where VA selects random samples of each of its
regional offices' decisions and assesses their accuracy in processing
and deciding such cases. For the TSGLI program, claim forms should be
reviewed by at least two staff members within a service's adjudication
office, and VA's contractor, the Office of Servicemembers' Group Life
Insurance, performs some checks on the claims before paying them.
According to the Office of Servicemembers' Group Life Insurance, claims
examiners check claims for obvious errors but do not review medical
documentation to determine the accuracy of the services' decisions. In
addition, 25 percent of claims are selected for an additional check,
which involves verifying information such as a servicemember's name,
bank account number, and payment amount.[Footnote 17] These checks have
identified some errors, according to VA officials. For example, one
servicemember with traumatic brain injury was initially approved by the
branch of service and told he would receive a benefit. However, upon
receiving the approved claim form, VA's contractor informed the service
that the claim should have been denied because his injury occurred in a
non-combat zone 5 months prior to the effective date of the program.
The service corrected the error and informed the servicemember that he
was not eligible for the program. While these checks have identified
some errors, they do not systematically examine whether the services'
decisions were correct, nor do they assess consistency within or across
the services.
In addition, VA officials noted that the TSGLI approval rates varied
across the services, but VA lacked sufficient information to explain
these differences. VA officials attributed the Marine Corps' higher
overall TSGLI approval rate--67 percent compared with Army's 53 percent
approval rate--to the Marine Corps' use of TSGLI staff in medical
treatment facilities to assist servicemembers in filing their claims.
However, without a quality assurance review process, DOD and VA cannot
determine whether differences in approval rates were due to these staff
members or to other factors.[Footnote 18]
Furthermore, while TSGLI allows servicemembers to request a
reconsideration or appeal, such a process may not identify whether
initial claim decisions were accurate or consistent across the services
for two reasons. First, not all servicemembers whose claims are denied
will request a claim review. Second, neither DOD nor VA use this
process to determine whether original decisions were accurate and
consistent across the program, because TSGLI officials from the
services told us they allow multiple reconsiderations where
servicemembers may submit new medical documentation to support their
claim.
During our review, VA officials told us that they planned to review a
sample of claim decisions and thought they could build an ongoing,
systematic quality assurance process out of this review. Officials told
us that, based on what they find, they could send out guidance or make
recommendations to the services to improve the accuracy and consistency
of TSGLI claim decisions. However, VA had not yet performed such a
review.
DOD and VA Lack Reliable, Sufficient Data to Oversee the Timeliness of
the Claims Process:
DOD and VA lack reliable, sufficient data for overseeing the timeliness
of the TSGLI claims process for servicemembers with traumatic brain
injury, an important tool in monitoring program performance.[Footnote
19] VA officials told us that they initially relied on data collected
by their contractor, but they recognized that these data do not include
all key aspects of the claim process, such as how long the services
take to make decisions on servicemembers' claims. As a result, VA
requested that the services begin collecting and reporting timeliness
data to VA monthly in the spring of 2007. However, we found these data
to be unreliable. VA officials acknowledged that there were some
problems with the data and stated that about one-third of the data they
collected from the services on claim processing times had dates missing
or out of sequence. For example, the date the servicemember signed the
claim form was prior to the date recorded for the traumatic event that
caused the servicemember's injury. Additionally, neither DOD nor VA can
assess whether claims for specific injuries take longer than others to
process because the data the services send to VA do not break out
claims by injury. VA and TSGLI service branch officials stated that the
services are generally able to process claims for amputations faster
than claims for traumatic brain injury, which involves an assessment of
a servicemember's ability to perform activities of daily living;
however, there are no data to support this observation.
Although VA lacks ongoing and reliable timeliness data, the agency
provided us with a reliable, point-in-time study of how many days it
took to process 238 claims from December 1, 2005, to December 31, 2006.
The sample showed that the services took, on average, 35 days to review
and make a decision on traumatic brain injury claims, compared with
their goal of processing claims within 30 days. During our review,
TSGLI officials from each service stated that their average processing
time was less than 30 days; however, VA does not have current, reliable
data to support this time frame.
VA's study of the first year of the TSGLI program showed that it took
about 180 days from the date a servicemember suffered a traumatic brain
injury to the date he or she received a benefit or denial letter. As
figure 4 shows, the time it took the services to process
servicemembers' claims represented only a small part of this overall
time. More than half of this 6-month period elapsed before the services
received servicemembers' claims.
Figure 4: VA Study on Average Timeliness of Key Steps in the Claims
Process from December 1, 2005, to December 31, 2006:
[Refer to PDF for image]
This figure is a stacked horizontal bar graph depicting the following
data:
Loss category: Loss of activities of daily living (ADL) due to
traumatic brain injury (TBI);
Date of injury to date of qualifying loss (at least 15 days for TBI and
30 days for OTI): 15.0 days;
Date of qualifying loss to date of claimant signature: 72.7 days;
Date of claimant signature to date of medical provider‘s signature:
19.5 days;
Date of medical provider‘s signature to date of receipt by service
branch: 31.0 days;
Date of receipt by service branch to date that service branch completes
review: 34.9 days;
Date service branch completes review to date of Office of
Servicemembers‘ Group Life Insurance (OSGLI) receipt of claim decision:
0.7 days;
Date of OSGLI receipt of claim decision to date that payment or denial
was issued: 5.9 days;
Total time: 179.7 days.
Loss category: Loss of ADLs due to other traumatic injuries (OTI);
Date of injury to date of qualifying loss (at least 15 days for TBI and
30 days for OTI): 30.0 days;
Date of qualifying loss to date of claimant signature: 72.1 days;
Date of claimant signature to date of medical provider‘s signature:
14.3 days;
Date of medical provider‘s signature to date of receipt by service
branch: 24.1 days;
Date of receipt by service branch to date that service branch completes
review: 18.8 days;
Date service branch completes review to date of Office of
Servicemembers‘ Group Life Insurance (OSGLI) receipt of claim decision:
1.0 days;
Date of OSGLI receipt of claim decision to date that payment or denial
was issued: 5.4 days;
Total time: 165.7 days.
Loss category: All other loss categories;
Date of injury to date of qualifying loss (at least 15 days for TBI and
30 days for OTI): 12.0 days;
Date of qualifying loss to date of claimant signature: 57.1 days;
Date of claimant signature to date of medical provider‘s signature:
18.5 days;
Date of medical provider‘s signature to date of receipt by service
branch: 34.8 days;
Date of receipt by service branch to date that service branch completes
review: 15.6 days;
Date service branch completes review to date of Office of
Servicemembers‘ Group Life Insurance (OSGLI) receipt of claim decision:
1.5 days;
Date of OSGLI receipt of claim decision to date that payment or denial
was issued: 6.5 days;
Total time: 146.1 days.
Source: Department of Veterans Affairs, Servicemembers‘ Group Life
Insurance Traumatic Injury Protection: Year One Review (July 2008).
[End of figure]
Servicemembers with Traumatic Brain Injury Have Faced Challenges in
Initiating Claims and Proving Eligibility for TSGLI Benefits, and DOD
and VA Have Taken Steps to Address These Challenges:
Servicemembers with traumatic brain injury have faced three major
challenges to accessing TSGLI benefits--initiating claims, proving that
they met eligibility criteria, and providing adequate documentation to
support their claims--and DOD and VA have taken a number of steps to
address these challenges. For example, DOD has placed TSGLI staff into
major medical facilities to assist servicemembers with initiating and
filing their claims.
Servicemembers Have Faced Difficulties in Initiating Claims, and DOD
Has Placed TSGLI Staff in Major Medical Facilities to Assist Them:
Although TSGLI benefits are intended as a quick, short-term benefit,
servicemembers with traumatic injuries, including traumatic brain
injury, have faced difficulties in initiating claims soon after their
injuries. Servicemembers and TSGLI staff that we interviewed told us
that support from family immediately after a traumatic injury is
important for recovery, and that benefits may enable family members to
leave their jobs and relocate to stay with the servicemember during his
or her treatment or rehabilitation. For example, one servicemember we
interviewed told us that the money he received from TSGLI allowed his
family to travel with him to three different hospitals, while another
servicemember stated that the money helped his mother, who did not work
for 3 months to stay with him during recovery. However, within the
first year of the TSGLI program, VA estimated it took servicemembers
with traumatic brain injury an average of nearly 3 months to initiate a
TSGLI claim. Based on interviews we conducted with servicemembers with
traumatic brain injury who applied for TSGLI benefits, the time it took
after their injury to initiate a claim ranged from 1 week to 11 months.
Servicemembers with traumatic brain injury have experienced three
primary difficulties in initiating TSGLI claims, according to VA and
service branch TSGLI officials and servicemembers we interviewed. While
there may be other reasons servicemembers waited to apply, many
servicemembers did not initiate claims soon after their injuries due to
the nature and severity of their traumatic injuries, a lack of
awareness of the program, and a lack of assistance in filing the claim.
[Footnote 20] For example:
* Many servicemembers with traumatic brain injury have had multiple
severe injuries, and they and their families may have initially focused
on treatment and recovery, rather than on benefits. For example, one
servicemember we interviewed with a traumatic brain injury told us he
did not apply for a TSGLI benefit until more than 2 months after his
injury occurred because he was focusing on treating his other injuries-
-burns to both of his arms.
* Many servicemembers with traumatic brain injury and their families
were not aware of TSGLI benefits immediately after the servicemember
was injured. One servicemember we interviewed suffered a traumatic
brain injury and was in a coma for 3 months due to an automobile
accident while on duty in the United States. He spent nearly 8 months
in three civilian hospitals and told us he was not aware of the TSGLI
program. However, once the servicemember arrived at a VA Medical
Center, he told us a TSGLI staff member recognized he would be eligible
for benefits and helped him collect medical records from civilian
medical providers to support his claim. Many servicemembers learned
about TSGLI a month or more after their injury, according to a 2007 VA
survey, and often through informal channels like friends or fellow
servicemembers.
* Many servicemembers did not have assistance in gathering medical
documentation and filling out the claim form. For example, one
servicemember in the National Guard who was taken to a civilian
hospital after a car accident in 2007 told us she did not receive
assistance in filing her claim and that she had difficulty in gathering
medical documentation for the claim. More than half of the
servicemembers in VA's survey did not receive assistance in filing
their TSGLI claims. In addition, many of the servicemembers we
interviewed, especially those who filed claims for injuries incurred
close or prior to the implementation of the program in 2005, did not
receive any assistance in initiating their claims.
DOD has recognized that servicemembers have faced difficulties in
initiating TSGLI claims and has placed TSGLI staff in major medical
treatment facilities to help raise awareness about the program and help
servicemembers navigate the claims process. One major medical treatment
facility--National Naval Medical Center in Bethesda, Maryland--has had
in-house Navy and Marine Corps TSGLI staff since early in the program
to help servicemembers. TSGLI specialists explain the program's
eligibility criteria, assist servicemembers with traumatic injuries in
putting together TSGLI claim packets, and act as advocates for the
servicemembers. Although they have not conducted a systematic
evaluation, DOD and VA officials have partly attributed the Navy's and
Marine Corps' higher TSGLI approval rates to this model and recommended
expanding it to other treatment facilities. As a result, DOD has placed
TSGLI staff in 10 of its largest medical treatment facilities--such as
Brooke Army Medical Center at Fort Sam Houston in Texas and Walter Reed
Army Medical Center in Washington, D.C.--to help additional
servicemembers navigate the claims process. Several of the
servicemembers we interviewed benefited from the assistance TSGLI staff
members provided. For example, the wife of one servicemember who
suffered a traumatic brain injury and several other injuries in Iraq
was unaware that her husband was eligible but told us a TSGLI staff
member came to her husband's hospital room to inform them about the
program and helped them apply for TSGLI.
Some servicemembers with traumatic brain injury are not treated at
these major medical treatment facilities and may not benefit from the
placement of TSGLI staff, but DOD and VA have proposed steps to provide
better outreach to these servicemembers. An Army official told us that
servicemembers are increasingly being treated at smaller hospitals,
including nonmilitary hospitals, and he has requested additional TSGLI
staff to expand their outreach. In addition, during our review, VA
completed a comprehensive year-one review of the TSGLI program and
proposed several steps to better reach out to servicemembers who may be
eligible for the program. For example, VA is exploring using military
and VA injury tracking data to periodically identify and notify
servicemembers whose injuries may make them eligible for a TSGLI
benefit. In addition, VA recently drafted a communications plan, which
includes steps such as developing Web-based training and a video on
TSGLI as well as revising materials for servicemembers making the
transition from military to civilian life and for military and VA staff
who assist them.
Servicemembers with Traumatic Brain Injury Have Faced Challenges in
Proving Their Eligibility for TSGLI, and VA Has Revised Guidance and
Criteria to Improve Access to the Program:
Servicemembers with traumatic brain injury have faced challenges in
proving they met eligibility requirements, because the criteria in
place at the time of our review for loss of activities of daily living
were subjective and unclear. For a servicemember to qualify for TSGLI
with a traumatic brain injury, a medical provider had to certify that
the servicemember was completely dependent on another person to perform
at least two of the six activities of daily living for at least 15
days. However, these criteria were subject to interpretation by
different medical providers because complete dependency on another
person was not clearly defined within the TSGLI claim form. For
example, medical providers told us that there may be differing opinions
on whether servicemembers with traumatic brain injury who require
verbal instructions to dress themselves are completely dependent on
another person to perform this activity. Some staff at medical
treatment facilities told us that medical providers at their facility
would only sign claim forms for loss of activities of daily living if a
servicemember was physically dependent on another person. In its year-
one review of the TSGLI program, VA acknowledged that the existing
guidance on applying the activities of daily living criteria was
complicated and subject to different interpretations. As a result,
claim decisions could have been inconsistent within and across the
services.
In fall 2008, VA revised the TSGLI claim form and guidance to clarify
the criteria for loss of activities of daily living. The form and
revised guidance clarify that a servicemember is unable to
independently perform an activity of daily living if he or she requires
either physical assistance, stand-by assistance,[Footnote 21] or verbal
assistance due to a cognitive impairment. See figure 5 for a comparison
of the revised claim form and the form in use at the time of our
review. Some of the servicemembers we interviewed may now be eligible
for benefits with the change in criteria to include stand-by and verbal
assistance. For example, one servicemember we interviewed who had a
skull fracture and shrapnel in his back from a blast injury in Iraq in
2004 was denied benefits because the service determined he was
physically able to perform all of the activities of daily living,
despite issues such as nausea and dizziness. However, according to
medical documentation, the servicemember is housebound and requires
significant assistance from his spouse to perform some activities, such
as bathing.
Figure 5: Comparison of the Previous and Revised TSGLI Claim Forms for
One Activity of Daily Living:
[Refer to PDF for image]
This figure is an illustration of the previous and revised TSGLI claim
forms for one activity of daily living, as follows:
Previous form:
Is this claim for inability to Dress?
Yes:
No:
If yes, please indicate the following:
1. Is/was the patient completely dependent upon another person to
dress/undress including:
a. pulling shirt on or off (pull-over or button-type shirt):
Yes:
No:
b. pulling pants on or off (pants, shorts, or sweat pants):
Yes:
No:
c. fastening garments (buttons or zippers):
Yes:
No:
d. securing equipment (braces, artificial limbs):
Yes:
No:
2. Is/was the patient able to use accommodating equipment or adaptive
behavior to dress:
Yes:
No:
3. Describe the specific physical limitations and how these limitations
prevent the patient from performing this activity:
4. When did the patient's inability to perform this activity begin and
end:
Begin date (mm/dd/yyyy):
End date (if applicable) (mm/dd/yyyy):
Check here if inability is on-going:
[End previous form]
Revised form:
Unable to dress independently:
Start date (mm/dd/yyyy):
End data (mm/dd/yyyy):
or, Check here if inability is on-going:
Type of assistance required (check all that apply):
physical assistance (hands-on):
stand-by assistance (within arm's reach):
verbal assistance (must be instructed because of cognitive impairment):
Patient is unable to dress independently if: he/she requires assistance
from another person to get and put on clothing, socks or shoes.
Describe assistance needed:
[End of revised form]
Sources: Department of Veterans Affairs, Application for TSGLI Benefits
(September 2006 and October 2008).
[End of figure]
While this revision to the TSGLI claim form and guidance will help
clarify the eligibility criteria, VA acknowledged that there are still
inherent difficulties in assessing servicemembers' ability to perform
activities of daily living. According to medical providers we
interviewed, assessing whether servicemembers can perform activities of
daily living still involves some subjectivity and professional
judgment. However, medical providers told us that the criteria of loss
of activities of daily living may be the best available measure for
TSGLI benefits because the medical community has not established one
objective test to measure a loss of functioning due to traumatic brain
injury that could substitute for the current criteria.
According to medical providers we interviewed, traumatic brain injury
is diagnosed through multiple assessment tools that are subjective in
nature, and these tools cannot easily quantify a loss in cognitive
functioning because the loss varies on the basis of the individual and
the context of the injury. One such assessment tool, a brain scan, may
indicate the area of the brain that is damaged but may not correlate to
the actual loss of cognitive functioning. For example, a servicemember
we interviewed with 35 years of military service sustained a blast
injury in Iraq in December 2006 that resulted in a concussion, and a
brain scan indicated damage to more than 60 percent of his brain.
However, he continued to perform his duties until he was advised to
seek medical attention because fellow servicemembers noticed a change
in his behavior. As a result of his traumatic brain injury, the
servicemember has been in treatment for over 2 years and continues to
have symptoms, such as difficulty in speaking and an inability to
sequence steps of a process. He is unable to drive and has gotten lost
in his own neighborhood. However, he was able to perform the activities
of daily living and did not qualify for TSGLI.
Servicemembers with Traumatic Brain Injury Have Lacked Adequate Medical
Documentation for Their TSGLI Claims, but VA Has Established an
Alternative to Address This Issue:
Servicemembers with traumatic brain injury have faced challenges in
proving they met eligibility criteria because they lacked medical
documentation with sufficient information on the length of time they
were unable to perform activities of daily living. According to some
medical providers and TSGLI staff we interviewed, notes in a
servicemember's medical file may not indicate whether the servicemember
was able to perform activities of daily living because such notes are
often oriented toward treatment and recovery, rather than documenting
the inability to perform certain activities. Medical providers said
that occupational therapists may perform assessments of activities of
daily living for servicemembers, but that these may only indicate a
servicemember's functional ability at one point in time, rather than at
the specified intervals of 15, 30, 60, or 90 days as required by TSGLI.
Furthermore, occupational therapy may not occur until after a
servicemember's injuries have been stabilized, which may be after the
qualifying period for documenting the inability to perform the
activities of daily living as required by TSGLI. In addition, VA and
TSGLI officials told us that challenges in documenting loss of
activities of daily living may have been greater for servicemembers
whose injuries occurred prior to the implementation of the program
because medical providers at major medical facilities may not have
routinely documented the loss of activities of daily living. Finally,
medical documentation may not have clearly stated that the
servicemember's inability to perform activities of daily living was
directly related to his or her traumatic brain injury, although such a
link is necessary to establish a servicemember's eligibility for TSGLI.
VA has recognized that documenting the loss of activities of daily
living for traumatic brain injury is difficult, and made a change in
the program to create another way for servicemembers to qualify for the
minimum TSGLI benefit. In its year-one review of the program, VA stated
that a 15-day continuous hospital stay from the time of the traumatic
brain injury is equivalent to the first 15 days of the inability to
perform activities of daily living. As a result, servicemembers with
traumatic brain injury who can document a 15-day hospital stay are now
eligible for a TSGLI benefit of $25,000. This change in eligibility
criteria, effective in November 2008, expands access to the TSGLI
program for servicemembers with traumatic brain injury.[Footnote 22]
For example, one of the servicemembers we interviewed had a traumatic
brain injury in addition to facial fractures and lacerations due to a
blast from an improvised explosive device in Iraq. He was denied for
TSGLI because he was able to document the loss of only one activity of
daily living--eating--but may qualify under the revised criteria
because he told us he was an inpatient for a month at a major medical
treatment facility.
DOD and VA officials told us that the services are reviewing all claims
that were denied or approved for less than the maximum amount to
determine if the servicemembers are now eligible for an initial or
higher TSGLI payment under the clarified guidance for the activities of
daily living criteria and the revised eligibility criteria. Officials
also told us they were exploring options, such as data matches with
military and VA injury tracking systems, to identify servicemembers who
never applied for TSGLI but may now be eligible.[Footnote 23]
Conclusions:
Three years after the creation of the TSGLI program, DOD and VA have
taken a number of important, proactive steps to improve the program for
all servicemembers, including those with traumatic brain injury. DOD
and VA efforts to improve program outreach, revise eligibility
criteria, and clarify guidance for assessing the inability to perform
activities of daily living will help expand access to the program to
more servicemembers with traumatic brain injury. However, given the
large population of servicemembers with traumatic brain injury,
determining who is eligible for TSGLI on the basis of the activities of
daily living may continue to present challenges because such
assessments involve subjectivity and require adequate, timely
documentation of a servicemember's functional abilities. Furthermore,
there is no alternative, objective test to quantify loss of functioning
due to traumatic brain injury. The military medical community is still
learning about traumatic brain injury and a great deal of research is
ongoing that might ultimately bring new tools for measuring traumatic
brain injury and understanding its short-and long-term effects on
individuals' lives. This research could prove useful to VA as the
agency seeks to continuously improve the TSGLI program for
servicemembers with traumatic brain injury.
Without a systematic quality assurance review process, DOD and VA lack
information on whether the services are consistently applying the
program eligibility criteria and making accurate decisions on
servicemembers' claims. Furthermore, the agencies lack assurance that
servicemembers with similar injuries, but in different services, are
receiving equitable treatment with respect to the TSGLI program.
In addition, by not addressing a software limitation that excludes some
traumatic brain injury denials from its data, VA lacks complete
information on the total universe of traumatic brain injury claimants
and the disposition of their claims. Such information is important for
understanding how well the program is working and for making any
adjustments to further enhance program performance. Finally, given that
the intent of the program is to provide a quick benefit to address
servicemembers' needs while they recover from their traumatic injuries,
timely decisions are important. While the services have goals for
reviewing and making decisions on servicemembers' claims and report
they are exceeding these goals, DOD and VA are unable to determine
whether they are actually meeting these goals without reliable data.
Furthermore, absent timeliness data broken out by type of injury, DOD
and VA are unable to determine whether servicemembers with traumatic
brain injury are experiencing unnecessary delays. Moreover, without
better data, VA and the services lack a reliable baseline from which to
determine whether new initiatives to improve the TSGLI program have the
desired effect.
Recommendations for Executive Action:
To improve management of the Servicemembers' Group Life Insurance
Traumatic Injury Protection Program (known as TSGLI) and ensure that
all injured servicemembers receive accurate, consistent, and timely
treatment, we recommend that the Secretary of Veterans Affairs work
with the Secretary of Defense and the branches of service to take the
following two actions:
* Implement a systematic quality assurance review process to help
ensure that TSGLI benefit decisions are accurate and consistent within
and across the services. For example, VA could expand its planned
review of a sample of TSGLI claim decisions into a systematic, ongoing
quality assurance review process.
* Take steps to ensure that the data required to assess approval rates
for traumatic brain injury and the timeliness of key steps in the TSGLI
claims process are reliable and comprehensive.
Agency Comments and Our Evaluation:
We presented a draft of this report to the Department of Defense; the
Department of Veterans Affairs; and VA's contractor, the Office of
Servicemembers' Group Life Insurance. DOD and VA provided written
comments, shown in appendixes II and III respectively, and VA provided
technical comments that we have incorporated into the report as
appropriate. The Office of Servicemembers' Group Life Insurance
provided oral comments, and we have incorporated them into the report
as appropriate.
DOD concurred with our recommendations. The agency agreed that a
quality assurance review process would help to ensure that claim
decisions are accurate and consistent, and noted that there is room for
improving data on the timeliness of TSGLI claims. While DOD agreed with
our recommendation to ensure that the data required to assess approval
rates for traumatic brain injury are reliable and comprehensive, the
agency cautioned that approval rates may not provide an accurate
assessment of the program. DOD noted that, initially, the branches of
service encouraged as many servicemembers as possible to apply for
TSGLI benefits--even if they may not be eligible--and this practice may
have inflated denial rates. DOD also provided some additional comments.
DOD noted that it believes a comparison of approval rates before and
after placement of TSGLI staff in medical facilities would indicate a
significant improvement. We agree that such an evaluation would be
useful in understanding the impact such staff have had on approval
rates, but neither DOD nor VA has conducted a study that compares
approval rates before and after the placement of TSGLI staff in medical
treatment facilities and controls for other factors that could
contribute to differences in approval rates.
VA also generally concurred with our recommendations. The agency
indicated that it will implement both of our recommendations and
outlined steps it plans to take to do so. However, regarding our
finding that DOD and VA lack assurance that TSGLI decisions are
accurate and consistent within and across the services, VA noted a
number of measures it has taken over the years to promote accuracy and
consistency. For example, VA cited checks at the Office of
Servicemembers' Group Life Insurance and regular conference calls to
discuss policy and unusual cases. We acknowledged these efforts in our
report, but maintain that such efforts do not provide sufficient
assurance that decisions are accurate and consistent within and across
the services. As we note in the report, officials from the Office of
Servicemembers' Group Life Insurance told us that their checks involve
verifying information such as the servicemember's name, bank account
number, and payment amount, rather than the accuracy and consistency of
decision making. VA also acknowledged that the current reviews do not
assess consistency across the services and recognized the need to
validate the accuracy and consistency of decisions made by the
services. VA reported that it is developing a quality assurance review
process that will include controls to look at the accuracy and
consistency of all cases before they are paid or a denial letter is
sent, as well as a statistically valid review of a sample of cases
after they are decided. VA anticipates full implementation of our
recommendation by July 1, 2009. Regarding our second recommendation on
improving the data required to assess approval rates for traumatic
brain injury and timeliness of key steps in the claims process, VA
noted that it is implementing procedures to reconcile missing or
inaccurate data and to clarify definitions with the services, and that
it will also begin collecting timeliness data by type of injury. The
agency anticipates full implementation of our recommendation by
September 30, 2009.
The Office of Servicemembers' Group Life Insurance also concurred with
our findings and recommendations and noted that they stand ready to
assist VA in implementing them.
We are sending copies of this report to interested congressional
committees, the Secretary of Defense, the Secretary of Veterans
Affairs, and the Office of Servicemembers' Group Life Insurance. The
report also is available at no charge on the GAO Web site at
[hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7215 or bertonid@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix IV.
Sincerely yours,
Signed by:
Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
The objectives of our report were to examine (1) the approval rate of
Servicemembers' Group Life Insurance Traumatic Injury Protection
Program (TSGLI) claims for traumatic brain injury, and whether the
Department of Defense (DOD) and the Department of Veterans Affairs (VA)
have assurance that claims are processed accurately, consistently, and
in a timely manner and (2) any challenges servicemembers with traumatic
brain injury may have faced in accessing TSGLI benefits, and the extent
to which DOD and VA have taken steps to address such challenges.
Data Reliability and Quality Assurance:
To address the first objective, we analyzed data VA gathered from its
contractor, the Office of Servicemembers' Group Life Insurance (OSGLI),
and the services on the number of claimants and the final disposition
and timeliness of their claims since the program's inception. We
restricted our scope to the Air Force, Army, Marine Corps, and Navy
because these four services represent nearly all (99.9 percent) of the
TSGLI applications filed.[Footnote 24]
To assess the reliability of data from OSGLI, the primary entity
responsible for recording data for the TSGLI program, we interviewed
officials from VA and OSGLI at the latter's offices in Roseland, New
Jersey. OSGLI officials demonstrated their data entry procedures and
explained their quality review processes. In addition, we randomly
selected and reviewed 100 TSGLI claimants' paper claim files,
representing 1 percent of all TSGLI claimants whose claims were decided
through June 30, 2008. We compared the data on the claim forms with the
data in OSGLI's electronic database. On the basis of this review, we
found that the data were sufficiently reliable to report the number of
claimants and the final disposition of their claims. However, we found
a number of limitations with respect to the number of traumatic brain
injury claimants and their dispositions. For example, (1) OSGLI and VA
do not include all traumatic brain injury denials in the traumatic
brain injury category in their data, which makes the actual approval
rate lower than reported and (2) the data system can only record one
claim and one primary injury per claimant.
To assess the reliability of data from the monthly reports the services
provide to VA, we interviewed TSGLI officials at the Air Force, Army,
Marine Corps, and Navy about the procedures they have in place to
ensure that the electronic data they keep are accurate. We found that,
while the services perform some spot checks of these data before
sending them to VA, they do not match the electronic data reported to
paper claim files. Also, the internal control procedures were not
robust enough to prevent a number of errors in the data. When VA
provided us with the data from the services as of June 30, 2008, VA
noted that they found that the electronic records for 277 out of 707
claims contained missing or out of sequence dates for key steps along
the process. For example, 43 records had key dates missing, such as the
date the servicemember signed his or her claim. In addition, for 95
records, the date recorded for the servicemember's signature on the
claim form was prior to the recorded date of the servicemember's
injury. Furthermore, VA shared that there had been some confusion among
the services over the definition of a key data element, the date of
loss.[Footnote 25] For some cases we reviewed, the dates in this field
did not match dates for the same field in VA's central data system,
even though data for both datasets came from the same source--submitted
claim applications.
We interviewed VA officials to assess the reliability of a one-time
study on the timeliness of key steps in the claims process. VA
collected the data from this study from a random sample of 238 claim
forms, stratified by injury. According to VA officials, this study
represented claims decided between December 1, 2005, and December 31,
2006, for injuries that occurred after the effective date of the
program on December 1, 2005, known as prospective claims. We found
these data to be reliable and representative of claimants with
traumatic brain injury for that period.
Finally, we interviewed DOD, VA, service branch, and OSGLI officials on
the procedures in place to ensure accuracy and consistency of decision
making. Additionally, we reviewed TSGLI procedure guides.
Challenges for Servicemembers with Traumatic Brain Injury:
To address the second objective, we interviewed DOD and VA officials
and reviewed TSGLI enacting legislation and regulations, program
guidance issued by DOD, VA, and the services as well as the program
procedural guide, published August 2007. We also reviewed VA's year-one
review of the TSGLI program, published in July 2008, and related
materials, including interim final regulations, VA's revised procedural
guide, and the new TSGLI claim form. In addition, we attended a
September 2008 training session for TSGLI officials and other relevant
staff on the proposed changes in guidance and changes to eligibility
criteria.
We interviewed TSGLI officials responsible for adjudicating and
certifying claims and conducting outreach to prospective claimants at
the Army, Air Force, Marine Corps, and Navy to learn about how they
decide claims; understand the policies each service has in place to
guide the disposition of claims; and determine what, if any, challenges
complicate the adjudication process, specifically for servicemembers
with traumatic brain injury.
We discussed challenges in accessing TSGLI benefits with 31
servicemembers with traumatic brain injury or their family members, in
both group and individual interviews. These servicemembers represented
those who (1) had not yet applied for TSGLI benefits, (2) were in the
process of applying for TSGLI benefits, (3) had applied and been
approved for TSGLI benefits, or (4) had applied and been denied for
TSGLI benefits. The servicemembers we interviewed included both
retroactive claimants and prospective claimants. Specifically, we
discussed these challenges with servicemembers with traumatic brain
injury and, in some cases, their family members; medical providers; and
service branch TSGLI staff at the following four medical treatment
facilities: Brooke Army Medical Center at Fort Sam Houston in Texas;
National Naval Medical Center, Bethesda, Maryland; Walter Reed Army
Medical Center, Washington, D.C.; and the Polytrauma Rehabilitation
Center at the Hunter Holmes McGuire VA Medical Center, Richmond,
Virginia. We selected these sites because they represent three of DOD's
larger medical treatment facilities for traumatic brain injury cases
and one of VA's four designated traumatic brain injury centers. We
conducted 4 group interviews with 14 servicemembers at Brooke Army
Medical Center and 1 group interview with 6 servicemembers at Walter
Reed Army Medical Center. We conducted six individual interviews with
servicemembers or family members at the other two treatment facilities.
We also completed five telephone interviews with servicemembers or
their family members. To conduct these interviews, we drew a random
sample of 60 servicemembers from the population of the 821
servicemembers who applied for TSGLI as of June 30, 2008, under the
traumatic brain injury category, stratified to include (1) denied and
approved claimants, (2) retroactive and prospective claimants, and (3)
claimants from each of the services. From that random sample, we
contacted servicemembers on the list until we completed five
interviews. Servicemembers were removed from the list if their
telephones had been disconnected or were no longer valid, they were not
living in the United States, or they could not be reached after two
separate attempts to contact them.
In addition, we discussed the nature of traumatic brain injury and
challenges that servicemembers with traumatic brain injury may face in
applying for TSGLI with medical professionals at the Defense and
Veterans Brain Injury Center as well as the Brain Injury Association of
America. We also interviewed representatives from three military and
veterans' advocacy groups--Iraq and Afghanistan Veterans of America,
Disabled American Veterans, and the Wounded Warrior Project.
Furthermore, we reviewed data from a customer satisfaction survey of
servicemembers who applied for TSGLI benefits conducted by VA's
contractor and found these data to be reliable for our purposes. We
confirmed that the sample population was representative of the TSGLI
population and verified that the contact method for the interview and
questions asked did not bias the results.
[End of section]
Appendix II: Comments from the Department of Defense:
Under Secretary Of Defense:
Personnel And Readiness:
4000 Defense Pentagon:
Washington, D.C. 20301-4000:
December 23, 2008:
Mr. Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, D.C. 20548:
Dear Mr. Bertoni:
This is the Department of Defense (DoD) response to the GAO draft
report, "Traumatic Brain Injury: Better DoD and VA Oversight Can Help
Ensure More Accurate, Consistent, and Timely Decisions for Traumatic
Injury Insurance Program," dated November 20, 2008, (GAO Code
130823/GAO-09-108).
The Department notes GAO has retitled the draft report by its primary
finding, which does not address the initial study purpose - Traumatic
Group Life Insurance Program for Service members with Traumatic Brain
Injury. Our preference is that the title be amended to reflect the
report content, not a single finding.
Examination of the approval rates for Traumatic Servicemembers' Group
Life Insurance (TSGLI) claims submitted for Traumatic Brain Injury may
not provide an accurate assessment of the program. Many members,
especially early in the TSGLI program, were encouraged to submit claims
even if they believed that the claim would ultimately be denied. The
opinion that, "I'll make them tell me 'no'" was encouraged by the
Services early in the program to ensure that members did not slip
through the eligibility process. However, it resulted in claim denial
rates that were inflated.
The report states that the Department of Veterans Affairs (VA)
attributes the higher approval rate experienced by the Marine Corps as
likely due to efforts to place TSGLI staff in medical facilities.
However, the report notes that without a quality assurance review,
there is no way to accurately determine the reason for the difference.
We believe that a comparison of the claim approval rates before
placement of TSGLI staff in medical facilities to the rates experienced
after placement of staff would indicate a significant improvement.
Indeed, that comparison, between pre-placement and post-placement of
TSGLI personnel in medical facilities, led the DoD to encourage other
military departments to make the same personnel transfers. The random
sample of 100 cases likely included claim experiences that occurred
both before and after the process was improved.
We agree that a quality assurance review process would help to ensure
that claim examination is accurate and consistent. Although the VA and
DoD have communicated regularly on TSGLI issues through monthly
conference calls and routine correspondence, a formal review process
does not exist. Further, the VA is the logical agency to staff and fund
the reviewing body since they are the agency tasked in Title 38 to
promulgate regulations in support of TSGLI.
Please address comments or questions to Mr. Tim Fowlkes at (703) 697-
3793, or tim.fowlkes@osd.mil.
Sincerely,
Signed by:
David S. C. Chu:
Enclosure: Formal Comments:
GAO Draft Report - Dated November 20, 2008:
GAO Code 130823/GAO-09-108:
"Traumatic Brain Injury: Better DoD and VA Oversight Can Help Ensure
More Accurate, Consistent, and Timely Decisions for Traumatic Injury
Insurance Program"
Department Of Defense Comments To The Recommendations:
Recommendation 1: The GAO recommends that the Secretary of Veterans
Affairs work with the Secretary of Defense and the branches of Service
to implement a systematic quality assurance review process to help
ensure that the Servicemembers' Group Life Insurance Traumatic Injury
Protection Program (TSGLI) benefit decisions are accurate and
consistent within and across the branches of Service.
DOD Response: Concur. An increased level of quality assurance will
benefit the TSGLI program. Because some of the TSGLI implementing
regulations and procedural guidance leave room for interpretation,
especially those sections related to Traumatic Brain Injury (TBI) and
Post Traumatic Stress Disorder (PTSD), a quality assurance review
process should improve the overall program. In addition, the revision
to TSGLI policy, published as a result of the Year One Review on
November 26, 2008 should greatly improve consistency among the
Services.
Recommendation 2: The GAO recommended that the Secretary of Veterans
Affairs work with the Secretary of Defense and the branches of Service
to take steps to ensure the data required to assess approval rates for
traumatic brain injury and the timeliness of key steps in the
Servicemembers' Group Life Insurance Traumatic Injury Protection
Program (TSGLI) claims process are reliable and comprehensive.
DOD Response: Concur. The report accurately references the laudable
efforts that DOD has taken to assist Soldiers in initiating claims, as
well as establishing and documenting their eligibility. Significant
progress has been made through DoD and VA efforts to document and
report the timeliness of TSGLI claim submission and the payment of
claims, however, room for improvements within the process exists.
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
December 22, 2008:
Mr. Daniel Bertoni:
Director:
Education, Workforce and Income Security Issues:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Bertoni:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, Traumatic Brain Injury:
Better DOD and VA Oversight Can Help Ensure More Accurate, Consistent,
and Timely Decisions for Traumatic Injury Insurance Program (GAO-09-
108) and generally agrees with its findings and recommendations.
VA and Department of Defense leadership remain committed to the
Traumatic Injury Insurance Program and to making necessary improvements
to the program to address the short-term financial burdens
traumatically injured service members and their families face. The
enclosure discusses GAO's recommendations in detail. It also suggests
some technical clarification for the report's overall accuracy. VA
appreciates the opportunity to comment on your draft report.
Sincerely yours,
Signed by:
James B. Peake, M.D.
Enclosure:
Department of Veterans Affairs (VA):
Response to GAO Draft Report:
Traumatic Brain Injury: Better DOD and VA Oversight Can Help Ensure
More Accurate, Consistent, and Timely Decisions for Traumatic Injury
Insurance Program (GAO-09-108):
GAO Recommendations:
To improve management of the Servicemembers' Group Life Insurance
Traumatic Injury Protection Program (known as TSGLI) and ensure that
all injured service members receive consistent, accurate, and timely
treatment, GAO recommends that the Secretary of Veterans Affairs work
with the Secretary of Defense and the branches of service to take the
following two actions:
Recommendation 1: Implement a systematic quality assurance review
process to help ensure that TSGLI benefit decisions are accurate and
consistent within and across the branches of service. For example, VBA
could expand its planned reviews of a sample of TSGLI claim decisions
into a systematic, ongoing quality assurance review.
Response: Concur. However, we believe that the underlying finding that,
"...DOD and VBA lack assurance that TSGLI decisions are accurate and
consistent across the services...," while true as stated, is misleading
without clarification. While it is accurate to say there has been no
statistically valid sampling to determine consistency among branches of
service, there have been a number of measures in place since the
beginning of the program to promote accuracy and consistency.
When the Office of Servicemembers' Group Life Insurance (OSGLI) began
paying TSGLI claims in December 2005, claims examiners reviewed medical
records and other documentation to ensure that the claim had been
adjudicated properly by the branch of service. In addition, 100 percent
of TSGLI claims were subject to OSGLI's Internal Quality Review process
for accuracy in the preparation of the award. By the summer of 2006,
the potential error rate for TSGLI claims was reduced significantly
from December 2005, when the program began, and the claims examiners,
although continuing to closely review the claims, no longer received or
reviewed any attending medical documentation. Furthermore, the
percentage of TSGLI claims reviewed was reduced to 25 percent-the same
percentage of Servicemembers' Group Life Insurance death claims that go
through OSGLI's Quality Review. This review however, does not check for
consistency of decisions across the branches of service.
Additionally, the Veterans Benefits Administration (VBA) produced and
distributed to each branch of service a TSGLI Procedures Guide, which
provided detailed procedures and guidance on all aspects of the
program, and, VBA provided training to the branches regarding the
guide.
Finally, VBA and OSGLI held weekly (then bi-weekly and ultimately
monthly) conference calls with all of the branches of service
participating at the same time. The purpose of these calls was to
discuss issues related to the program and how they were addressed in
the Procedures Guide, and to discuss policy and concepts involving
novel issues or unusual claims. These issues were raised and guidance
was provided to ensure that all branches were handling case decisions
consistently.
During the course of the Year-One Review, VBA recognized the need for a
validation of the accuracy and consistency of case decisions made by
the branches of service and began discussions about developing and
implementing a statistically valid post-adjudicative review process.
Accordingly, VBA is in the process of developing an integrated quality
assurance review process that will include the branches of service,
OSGLI and VBA. This review will include both in-process controls to
look at the accuracy and consistency of all cases before they are paid
or a denial letter is sent, and a post-adjudicative, statistically
valid review of a sample of cases to validate the in-process review.
The review process will also include a detailed feedback mechanism for
the branches of service to ensure they make procedural adjustments as
necessary. VBA anticipates full implementation of this recommendation
by July 1, 2009.
Recommendation 2: Take steps to ensure the data required to assess
approval rates for traumatic brain injury and the timeliness of key
steps in the TSGLI claims process are reliable and comprehensive.
Response: Concur. In its report, GAO states that the TSGLI approval
rate for traumatic brain injury (TBI) claims may be lower than
documented because VBA's data does not include all denials for TBI. As
GAO indicates, this is due to a current system limitation that does not
allow claims to be recorded in the TBI category unless the medical
provider indicates a loss of at least one of the six activities of
daily living. System enhancements are being implemented that will allow
such claims to be captured as TBI claims.
GAO's report states that DOD and VBA lack reliable, sufficient data to
oversee the timeliness of the TSGLI claims process. Although VBA
believes the reported timeliness of TSGLI claims from the date of
injury to the date of payment is generally accurate, during the course
of the Year-One Review, VBA identified problems with the TSGLI
timeliness reports and began working with the branches of service to
reconcile the timeliness data they were providing. VBA is implementing
a systematic reconciliation process by which reports with missing or
inaccurate numbers are returned to the branches of service for
correction. In cases where dates cannot be provided (e.g. service
member does not date the form), procedures are being established on how
those cases will be handled. VBA is also clarifying definitions of the
timeliness milestones within the process (e.g., from date of injury to
date claim is submitted, and from date claim is submitted to date the
medical professional completes the form, etc.) to ensure that all
branches of service understand and report dates accurately and
consistently. Accurate interim milestones will help VBA and the
branches make further improvements in the overall timeliness of
processing TSGLI claims.
GAO states in its report that the data VBA collects from the branches
of service do not break out claims by injury type, and as a result, DOD
and VBA lack information on how long it takes the branches of service
to make decisions on TBI claims (and by inference other categories of
losses). In response, VBA is modifying the process to incorporate
injury type into the timeliness data so timeliness can be calculated by
injury type. VBA anticipates full implementation of this recommendation
by September 30, 2009.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Daniel Bertoni, (202) 512-7215 or bertonid@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, the following staff members
made important contributions to this report: Melissa Emrey-Arras,
Assistant Director; Rachael C. Valliere, Analyst in Charge; Martin E.
Scire; Jennifer E. Neer; Rebecca A. Wilson; Gary A. Bianchi; Timothy E.
Bazzle; Nora G. Boretti; and Linda L. Siegel. Also, S. Andrew Stavisky
and Walter K. Vance provided guidance on the study's design and data
analysis; Daniel A. Schwimer provided legal advice; and Mimi Nguyen and
Marc W. Molino created the report graphics. In addition, Susan C.
Bernstein advised the team on writing the report, and Lise L. Levie
verified our findings.
[End of section]
Footnotes:
[1] This RAND estimate is based on a survey of a representative sample
drawn from the population of all those who have been deployed for
Operation Enduring Freedom and Operation Iraqi Freedom. Of the 1,965
respondents, 19.5 percent reported experiencing a probable traumatic
brain injury during deployment.
[2] Our review focused on the Air Force, Army, Marine Corps, and Navy
because these services represent almost all of the TSGLI claims filed
as of June 30, 2008. However, we have included data from Coast Guard
claims in our analyses.
[3] According to the Defense and Veterans Brain Injury Center, less is
known about the nature of combat-related traumatic brain injury and the
short-and long-term outcomes for servicemembers, particularly those who
suffered brain injuries caused by blasts.
[4] Pub. L. No. 109-13 (2005); 38 U.S.C. § 1980A.
[5] All servicemembers paying premiums into the Servicemembers' Group
Life Insurance Program are automatically covered by TSGLI while they
are in service. According to the VA's Performance and Accountability
Report for fiscal year 2008, 99 percent of servicemembers were enrolled
in the Servicemembers' Group Life Insurance Program.
[6] Servicemembers may be eligible for retroactive benefits if their
injuries occurred during this time period while they were deployed
outside of the United States on orders in support of Operation Enduring
Freedom or Operation Iraqi Freedom or while they were serving in a
geographic location that qualified them for the Combat Zone Tax
Exclusion.
[7] For the purposes of this report, we will primarily use the term
injury. However, it is important to note that TSGLI provides
compensation for the eligible losses that result from these injuries--
such as a loss of hand or foot or, in the case of traumatic brain
injury, the loss of the ability to perform activities of daily living-
-rather than for the injuries themselves.
[8] VA officials explained this criterion by noting that TSGLI was not
intended to serve as a death benefit, and that requiring claimants to
survive at least 7 days preserves this intent.
[9] Injuries caused by a mental disorder, a mental or physical illness
or disease--unless caused by a pyogenic (pus forming, often from a
wound) infection, biological, chemical, or radiological weapon--or
attempted suicide are not covered by TSGLI. Furthermore, injuries
sustained while committing or attempting to commit a felony and
injuries caused by self-inflicted wounds; medical or surgical treatment
of an illness or disease; or willful use of an illegal or controlled
substance, unless administered or consumed on the advice of a medical
professional, are not covered.
[10] For example, a servicemember may have traumatic brain injury
causing an inability to perform activities of daily living for 30 days,
in addition to an amputation of one foot. If found eligible for TSGLI,
he or she would receive $50,000 for traumatic brain injury and $50,000
for the loss of one foot, for a total of $100,000. However, according
to TSGLI procedures, a servicemember may not combine payment for an
injury under the other traumatic injury category with payment for an
injury in another category.
[11] VA initially began making payments under an interim final rule
published in the Federal Register on December 22, 2005. The final rules
were published on March 8, 2007 (38 C.F.R. Part 9).
[12] According to agency officials, the purpose of these conference
calls is to discuss policy issues and unusual cases.
[13] There are other denials for traumatic brain injury that also are
not reflected in VA's central data system because this system only
records one claim per claimant and one primary injury category. For
example, a previously denied claim for traumatic brain injury may not
appear in VA's data if a later claim for a different injury was
approved for that individual. As a result, data may not reflect all
servicemembers who claimed a traumatic brain injury. However, officials
told us that tracking the number of servicemembers who receive benefits
is a better measure of the program's impact than tracking individual
claims.
[14] The data do not reflect denials that are in the process of being
appealed.
[15] In our limited review of a small sample of claim forms, traumatic
brain injury claims were denied due to a lack of medical documentation
to support the loss of ability to perform activities of daily living or
because the servicemembers' injuries occurred in a non-combat zone
prior to the effective date of the program, December 1, 2005.
[16] According to the Standards for Internal Control in the Federal
Government, internal control monitoring--one of five internal control
activities--should assess the quality of performance over time.
Internal controls should generally be designed to ensure that ongoing
monitoring occurs in the course of normal operations, including regular
management and supervisory activities, comparisons, reconciliations,
and other actions people take in performing their duties. See GAO,
Standards for Internal Control in the Federal Government, [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.:
November 1999).
[17] VA officials noted that early in the TSGLI program, claims
examiners from the Office of Servicemembers' Group Life Insurance
reviewed medical documentation to ensure the claim had been adjudicated
properly by the services. However, as of the summer of 2006, claims
examiners no longer receive or review medical documentation.
[18] In commenting on our draft report, DOD noted that it believed a
comparison of the approval rates before and after placing TSGLI staff
in medical treatment facilities would show a significant improvement.
However, neither DOD nor VA has conducted such an evaluation that would
control for other factors that could have contributed to different
approval rates between the two services.
[19] Government internal control standards require agencies to have
internal control activities to help ensure that data on the entire
process or life cycle of a transaction are complete and accurate to
support decision making. See [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1].
[20] In its Year-One Review of the TSGLI program, VA found that some
servicemembers may have delayed applying for TSGLI because it would
have prevented them from continuing to receive Combat-related Injury
and Rehabilitation Pay. However, Combat-related Injury and
Rehabilitation Pay has been replaced by the Pay and Allowances
Continuation Program, which is not linked to the receipt of a TSGLI
benefit.
[21] According to VA's revised TSGLI procedural guide, stand-by
assistance is defined as when a patient requires someone to be within
arm's reach because the patient's ability fluctuates and physical or
verbal assistance may be needed.
[22] This will also expand access to the program for servicemembers
with a 15-day hospital stay for other traumatic injuries. The 15-day
hospital stay will substitute for the first eligibility period for the
other traumatic injury category, which is 30 days.
[23] VA officials told us they are conducting data mining with the
Joint Patient Tracking and Veterans Tracking Applications to identify
veterans who may now be eligible for TSGLI.
[24] However, when reporting TSGLI data, we included the eight claims
that have been filed in the Coast Guard.
[25] The date of loss is the date a servicemember becomes eligible for
the TSGLI program. For example, a servicemember with traumatic brain
injury may be eligible for TSGLI benefits after he or she is unable to
perform the activities of daily living for at least 15 days.
[End of section]
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