This is the accessible text file for GAO report number GAO-09-108 entitled 'Traumatic Brain Injury: Better DOD and VA Oversight Can Help Ensure More Accurate, Consistent, and Timely Decisions for the Traumatic Injury Insurance Program' which was released on January 29, 2009. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. Please E-mail your comments regarding the contents or accessibility features of this document to Webmaster@gao.gov. This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. Because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. 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] GAO's Mission: The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. 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