Summary

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.

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.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

Recommendations for Executive Action