Traumatic Injury Servicemembers’ Group Life

Insurance (TSGLI)

NCC FursethNavy Casualty Assistance Division

Medical/Legal Review

• If additional medical review is required– Claim and supporting medical documentation is

forwarded to PERS or BUMED for review

• If further legal review is required– Claim and supporting documentation is

forwarded to NPC for review

Claim Certification

• Claim is approved, scanned and forwarded to Office of Servicemembers’ Group Life Insurance (OSGLI) for payment.

• Payment is usually issued within 72 hours

Denial Process

• Denied claims are scanned by N135C and forwarded to OSGLI

• OSGLI notifies the injured Sailor in writing that their claim was denied, the reason for denial, and briefly explains their right to appeal

• When a TSGLI claim is denied the injured Sailor can appeal

• Appeals of SGLI coverage are made directly to OSGLI, all others to N135C

Appeals

• Appeals must contain the following:– Sailor’s identifying information (name, address,

and social security number)– Reason the Sailor disagrees with the denial– Support documentation (i.e., medical records,

Physical Evaluation Board findings, etc.)– Written comments, documents, records, or any

other information which substantiates their claim

Appeals

• Decisions that are likely to be appealed:– Sailor’s loss did not qualify under TSGLI

– Loss was not a direct result of a traumatic event

– Loss was due to a physical or mental illness or a disease not covered under TSGLI

• First level appeals will be submitted to N135C for adjudication

• Second level appeals will be submitted directly to the Secretary of the Navy Council of Review Boards (CORB)

Common Errors

• Claims completed based on interviews with patient and not the result of witnessing the claimed loss or a review of medical documentation

• Adding losses to the claim form– If a loss is not on the form it is not covered

under TSGLI

Common Errors

• Incomplete or missing medical documentation

• Incomplete or missing data in Part B of the claim form

• Medical documentation does not support loss

• Independent Duty Corpsmen cannot sign claim form unless co-signed by a licensed physician

Common Errors

• Claim must be signed by a:– Licensed Physician– Optometrist– Nurse Practitioner– Registered Nurse or Physicians Assistant acting

within the scope of their practice

Ineligible Claims

• PTSD and Depressive Disorders– Sailors are encouraged to seek assistance from the VA

• TBI in and of itself– TBI must be associated with a scheduled loss (coma or

loss of Activities of Daily Living (ADLs))

• Cognitive Deficits– Must directly lead to losses of ADLs

• Other physical or mental illness or a disease not covered under TSGLI

• Losses not caused by a traumatic event

Further Information

• http://www.npc.navy.mil/CommandSupport/CasualtyAssistance/TSGLI/

• https://www.insurance.va.gov/sgliSite/ TSGLI/TSGLI.htm

Contact Info

• NCC Steven Furseth (Program Manager)

Steven.j.furseth@navy.mil - 901-874-6801

• HM1 Steven Marsh (Claims Adjudicator)

Steven.h.marsh@navy.mil - 901-874-4311

QUESTIONS?

The goal of Navy Casualty is to

“Lean Toward Yes”while staying within the program guidelines