**§9.20 Traumatic injury protection.**

\(a\) *What is traumatic injury protection?* Traumatic injury protection
provides for the payment of a specified benefit amount to a member
insured by Servicemembers' Group Life Insurance who sustains a traumatic
injury directly resulting in a scheduled loss.

\(b\) *What is a traumatic event?*

\(1\) A traumatic event is the application of external force, violence,
chemical, biological, or radiological weapons, or accidental ingestion
of a contaminated substance causing damage to a living being occurring:

\(i\) On or after December 1, 2005, or

\(ii\) On or after October 7, 2001, and through and including November
30, 2005, if the scheduled loss is a direct result of a traumatic injury
incurred in Operation Enduring Freedom or Operation Iraqi Freedom.

\(2\) (i) The term *incurred in Operation Enduring Freedom* means a
service member was deployed outside of the United States on orders in
support of Operation Enduring Freedom or served in a geographic location
that qualified the service member for the Combat Zone Tax Exclusion
under 26 U.S.C. 211.

\(ii\) The term *incurred in Operation Iraqi Freedom* means a service
member was deployed outside of the United States on orders in support of
Operation Iraqi Freedom or served in a geographic location that
qualified the service member for the Combat Zone Tax Exclusion under 26
U.S.C. 211.

\(3\) A traumatic event does not include a medical or surgical procedure
in and of itself.

\(c\) *What is a traumatic injury?*

\(1\) A traumatic injury is physical damage to a living body that is
caused by a traumatic event as defined in paragraph (b) of this section.

\(2\) For purposes of this section, the term "traumatic injury" does not
include damage to a living body caused by:

\(i\) A mental disorder; or

\(ii\) A mental or physical illness or disease, except if the physical
illness or disease is caused by a pyogenic infection, biological,
chemical, or radiological weapons, or accidental ingestion of a
contaminated substance.

\(3\) For purposes of this section, all traumatic injuries will be
considered to have occurred at the same time as the traumatic event.

\(d\) *What are the eligibility requirements for payment of traumatic
injury protection benefits?* You must meet all of the following
requirements in order to be eligible for traumatic injury protection
benefits.

\(1\) You must be a member of the uniformed services who is insured by
Servicemembers' Group Life Insurance under section 1967(a)(1)(A)(i), (B)
or (C)(i) of title 38, United States Code, on the date you sustained a
traumatic injury, except if you are a member who experienced a traumatic
injury on or after October 7, 2001, through and including December 1,
2005, and your scheduled loss was a direct result of injuries incurred
in Operation Enduring Freedom or Operation Iraqi Freedom. (For this
purpose, you will be considered a member of the uniformed services until
midnight on the date of termination of your duty status in the uniformed
services that established your eligibility for Servicemembers' Group
Life Insurance, notwithstanding an extension of your Servicemembers'
Group Life Insurance coverage under section 1968(a) of title 38, United
States Code.)

\(2\) You must suffer a scheduled loss that is a direct result of a
traumatic injury and no other cause.

\(3\) You must survive for a period not less than seven full days from
the date of the traumatic injury. The seven day period begins on the
date and Zulu (Greenwich Meridian) time of the traumatic injury and ends
168 full hours later.

\(4\) You must suffer a scheduled loss under paragraph (e)(7) of this
section within two years of the traumatic injury.

\(5\) You must suffer a traumatic injury before midnight on the date of
termination of your duty status in the uniformed services that
established eligibility for Servicemembers' Group Life Insurance. For
purposes of this section, the scheduled loss may occur after the date of
termination of your duty status in the uniformed services that
established eligibility for Servicemembers' Group Life Insurance.

\(e\) *What is a scheduled loss and what amount will be paid because of
that loss?*

\(1\) The term "scheduled loss" means a condition listed in the schedule
in paragraph (e)(7) of this section if directly caused by a traumatic
injury. A scheduled loss is payable at the amount specified in the
schedule.

\(2\) The maximum amount payable under the schedule for all losses
resulting from traumatic events occurring within a seven-day period is
\$100,000. We will calculate the seven-day period beginning with the day
on which the first traumatic event occurs.

\(3\) A benefit will not be paid if a scheduled loss is due to a
traumatic injury:

\(i\) Caused by:

> \(A\) The member's attempted suicide, while sane or insane;
>
> \(B\) An intentionally self-inflicted injury or an attempt to inflict
> such injury;
>
> \(C\) Diagnostic procedures, preventive medical procedures such as
> inoculations, medical or surgical treatment for an illness or disease,
> or any complications arising from such procedures or treatment;
>
> \(D\) Willful use of an illegal substance or a controlled substance
> unless administered or consumed on the advice of a medical
> professional; or
>
> \(ii\) Sustained while a member was committing or attempting to commit
> a felony.

\(4\) A benefit will not be paid for a scheduled loss resulting from:

\(i\) A physical or mental illness or disease, whether or not caused by
a traumatic injury, other than a pyogenic infection or physical illness
or disease caused by biological, chemical, or radiological weapons or
accidental ingestion of a contaminated substance; or

\(ii\) A mental disorder whether or not caused by a traumatic injury.

\(5\) Amount Payable under the Schedule of Losses.

\(i\) The maximum amount payable for all scheduled losses resulting from
a single traumatic event is limited to \$100,000. For example, if a
traumatic event on April 1, 2006, results in the immediate total and
permanent loss of sight in both eyes, and the loss of one foot on May 1,
2006, as a direct result of the same traumatic event, the member will be
paid \$100,000.

\(ii\) If a member suffers more than one scheduled loss from separate
traumatic events occurring more than seven full days apart, the
scheduled losses will be considered separately and a benefit will be
paid for each loss up to the maximum amount according to the schedule.
For example, if a member suffers the loss of one foot at or above the
ankle on May 1, 2006, from one event, the member will be paid \$50,000.
If the same member suffers loss of sight in both eyes from an event that
occurred on November 1, 2006, the member will be paid an additional
\$100,000.

\(6\) Definitions. For purposes of this paragraph (e)(6):

\(i\) The term *quadriplegia* means the complete and irreversible
paralysis of all four limbs.

\(ii\) The term *paraplegia* means the complete and irreversible
paralysis of both lower limbs.

\(iii\) The term *hemiplegia* means the complete and irreversible
paralysis of the upper and lower limbs on one side of the body.

\(iv\) The term *uniplegia* means the complete and irreversible
paralysis of one limb of the body.

\(v\) The term *complete and irreversible paralysis* means total loss of
voluntary movement resulting from damage to the spinal cord or
associated nerves, or to the brain, that is deemed clinically stable and
unlikely to improve.

\(vi\) The term *inability to carry out activities of daily living*
means the inability to independently perform at least two of the six
following functions:

> \(A\) Bathing.
>
> \(B\) Continence.
>
> \(C\) Dressing.
>
> \(D\) Eating.
>
> \(E\) Toileting.
>
> \(F\) Transferring in or out of a bed or chair with or without
> equipment.

\(vii\) The term *pyogenic infection* means a pus-producing infection.

\(viii\) The term *contaminated substance* means food or water made
unfit for consumption by humans because of the presence of chemicals,
radioactive elements, bacteria, or organisms.

\(ix\) The term *chemical weapon* means chemical substances intended to
kill, seriously injure, or incapacitate humans through their
physiological effects.

\(x\) The term *biological weapon* means biological agents or
microorganisms intended to kill, seriously injure, or incapacitate
humans through their physiological effects.

\(xi\) The term *radiological weapon* means radioactive materials or
radiation-producing devices intended to kill, seriously injure, or
incapacitate humans through their physiological effects.

\(xii\) The term *medical professional* means a licensed practitioner of
the healing arts acting within the scope of his or her practice. Some
examples include a licensed physician, optometrist, nurse practitioner,
registered nurse, physician assistant, or audiologist.

\(xiii\) The term *hospitalization* means an inpatient stay in a
facility that is:

\(A\) (*1*) Accredited by the Joint Commission or its predecessor, the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO),
or accredited or approved by a program of the qualified governmental
unit in which such institution is located if the Secretary of Health and
Human Services has found that the accreditation or comparable approval
standards of such qualified governmental unit are essentially equivalent
to those of the Joint Commission or JCAHO;

(*2*) Used primarily to provide, by or under the supervision of
physicians, to inpatients diagnostic services and therapeutic services
for medical diagnosis, treatment, and care of injured, disabled, or sick
persons;

(*3*) Requires every patient to be under the care and supervision of a
physician; and

(*4*) Provides 24-hour nursing services rendered or supervised by a
registered professional nurse and has a licensed practical nurse or
registered nurse on duty at all times; or

\(B\) Any Armed Forces medical facility that is authorized to provide
inpatient and/or ambulatory care to eligible service members.

\(xiv\) The term *total and permanent loss of sight* means:

\(A\) Visual acuity in the eye of 20/200 or less (worse) with corrective
lenses lasting at least 120 days;

\(B\) Visual acuity in the eye of greater (better) than 20/200 with
corrective lenses and a visual field of 20 degrees or less lasting at
least 120 days; or

\(C\) Anatomical loss of the eye.

\(xv\) The term *total and permanent loss of speech* means organic loss
of speech or the ability to express oneself, both by voice and whisper,
through normal organs for speech, notwithstanding the use of an
artificial appliance to simulate speech. Loss of speech must be
clinically stable and unlikely to improve.

\(xvi\) The term *total and permanent loss of hearing* means average
hearing threshold sensitivity for air conduction of at least 80
decibels, based on hearing acuity measured at 500, 1,000, and 2,000
Hertz, that is clinically stable and unlikely to improve.

\(xvii\) The term *burns* means 2nd degree (partial thickness) or worse
burns covering at least 20 percent of the body, including the face and
head, or 20 percent of the face alone. Percentage of the body burned may
be measured using the Rule of Nines or any means generally accepted
within the medical profession.

\(xviii\) The term *coma* means a state of profound unconsciousness that
is measured at a Glasgow Coma Score of 8 or less.

\(xix\) The term *limb salvage* means a series of operations designed to
save an arm or leg with all of its associated parts rather than amputate
it. For purposes of this section, a surgeon must certify that the option
of amputation of the limb(s) was a medically justified alternative to
salvage, and the patient chose to pursue salvage.

\(xx\) The term *amputation* means the severance or removal of a limb or
part of a limb resulting from trauma or surgery. An amputation above a
joint means a severance or removal that is closer to the body than the
specified joint is.

\(f\) Schedule of Losses.

For losses listed in paragraphs (f)(1) through (18) of this section,
multiple losses resulting from a single traumatic event may be combined
for purposes of a single payment (except where noted otherwise);
however, the total payment amount may not exceed \$100,000 for losses
resulting from a single traumatic event.

Payments for losses listed in paragraphs (f)(19) through (20) of this
section may not be made in addition to payments for losses under
paragraphs (f)(1) through (18)---only the higher amount will be paid.
The total payment amount may not exceed \$100,000 for losses resulting
from a single traumatic event.

If the loss is--- Then the amount payable for that loss is---

**(1) Total and permanent loss of sight:**

• For each eye \$50,000

**(2) Total and permanent loss of hearing:**

• For one ear \$25,000

• For both ears \$100,000

**(3) Total and permanent loss of speech** \$50,000

**(4) Quadriplegia** \$100,000

**(5) Hemiplegia** \$100,000

**(6) Paraplegia** \$100,000

**(7) Uniplegia:**

• For each limb\* \$50,000

*\*Note: Payment for uniplegia of arm cannot be combined with loss 9,*

*10, or 14 for the same arm. Payment of uniplegia of leg cannot be*

*combined with loss 11, 12, 13, or 15 for the same leg.*

**(8) Burns** \$100,000

**(9) Amputation of a hand at or above the wrist:**

• For each hand\* \$50,000

*\*Note: Payment for loss 9 cannot be made in addition to payment*

*for loss 10 for the same hand.*

**(10) Amputation at or above the metacarpophalangeal joint(s)**

**of either the thumb or the other 4 fingers on 1 hand:**

• For each hand\* \$50,000

*\*Note: Payment for loss of the thumb cannot be made in addition*

*to payment for loss of the other 4 fingers for the same hand.*

**(11) Amputation of a foot at or above the ankle:**

• For each foot\* \$50,000

*\*Note: Payment for loss 11 cannot be made in addition to payments*

*for losses 12 or 13 for the same foot.*

**(12) Amputation at or above the metatarsophalangeal joints of all**

**toes on 1 foot:**

• For each foot\* \$50,000

*\*Note: Payment for loss 12 cannot be made in addition to payments*

*for loss 13 for the same foot.*

**(13) Amputation at or above the metatarsophalangeal joint(s) of
either**

**the big toe, or the other 4 toes on 1 foot:**

• For each foot \$25,000

**(14) Limb salvage of arm:**

• For each arm\* \$50,000

*\*Note: Payment for loss 14 cannot be made in addition to payments*

*for losses 9 or 10 for the same arm.*

**(15) Limb salvage of leg:**

• For each leg\* \$50,000

*\*Note: Payment for loss 15 cannot be made in addition to payments*

*for losses 11, 12 or 13 for the same leg.*

**(16) Facial Reconstruction:**

• Jaw---surgery to correct discontinuity loss of

of the upper or lower jaw \$75,000

• Nose---surgery to correct discontinuity loss of

50% or more of the cartilaginous nose \$50,000

• Lips---surgery to correct discontinuity loss of

50% or more of the upper or lower lip

\- For one lip \$50,000

\- For both lips \$75,000

• Eyes---surgery to correct discontinuity loss of

30% or more of the periorbita

\- For each eye \$25,000

• Facial Tissue---surgery to correct discontinuity loss in

50% or more of any of the following facial subunits:

forehead, temple, zygomatic, mandibular, infraorbital

or chin

\- For each facial subunit \$25,000

*Note 1: Losses due to facial reconstruction may be combined with each*

*other, but the maximum benefit for facial reconstruction may not*

*exceed \$75,000.*

*Note 2: Any injury or combination of losses under facial
reconstruction*

*may also be combined with other losses in paragraphs 9.20(f)(1)--(18)
and*

*treated as one loss, provided that all losses are the result of a
single*

*traumatic event. However, the total payment amount may not exceed
\$100,000.*

**(17) Coma from traumatic injury AND/OR Traumatic Brain Injury
resulting**

**in inability to perform at least 2 Activities of Daily Living (ADL)**

• at 15th consecutive day of coma or ADL loss\* \$25,000

• at 30th consecutive day of coma or ADL loss\* an additional \$25,000

• at 60th consecutive day of coma or ADL loss\* an additional \$25,000

• at 90th consecutive day of coma or ADL loss\* an additional \$25,000

*\*Note: Duration of coma and inability to perform ADLs includes date*

*of onset of coma or inability to perform ADLs and the first date on
which*

*member is no longer in a coma or is able to perform ADLs.*

**(18) Hospitalization due to traumatic brain injury\***

• at 15th consecutive day of hospitalization\*\* \$25,000

*\*Note: Payment for hospitalization replaces the first payment*

*period in loss 17.*

*\*\*Note: Duration of hospitalization includes dates on which member*

*is transported from the injury site to a facility described in
§9.20(e)(6)(xiii),*

*admitted to the facility, transferred between facilities, and
discharged*

*from the facility.*

**(19) Traumatic injury, other than traumatic brain injury, resulting
in**

**inability to perform at least 2 Activities of Daily Living (ADL)**

• at 30th consecutive day of ADL loss\* \$25,000

• at 60th consecutive day of ADL loss\* an additional \$25,000

• at 90th consecutive day of ADL loss\* an additional \$25,000

• at 120th consecutive day of ADL loss\* an additional \$25,000

*Note: Duration of inability to perform ADLs includes date*

*of onset of inability to perform ADLs and the first date*

*on which member is able to perform ADLs.*

**(20) Hospitalization due to traumatic injury other than traumatic
brain injury\***

• at 15th consecutive day of hospitalization\*\* \$25,000

*\*Note: Payment for hospitalization replaces the first payment*

*period in loss 19.*

*\*\*Note: Duration of hospitalization includes dates on which member*

*is transported from the injury site to a facility described in
§9.20(e)(6)(xiii),*

*admitted to the facility, transferred between facilities, and
discharged*

*from the facility.*

\(g\) *Who will determine eligibility for traumatic injury protection
benefits?* Each uniformed service will certify its own members for
traumatic injury protection benefits based upon section 1032 of Public
Law 109-13, section 501 of Public Law 109-233, and this section. The
uniformed service will certify whether you were at the time of the
traumatic injury insured under Servicemembers' Group Life Insurance and
whether you have sustained a qualifying loss.

\(h\) *How does a member make a claim for traumatic injury protection
benefits?*

\(1\) (i) A member who believes he or she qualifies for traumatic injury
protection benefits must complete Part A of the Application for TSGLI
Benefits Form and sign the form.

\(ii\) If a member is unable to sign the Application for TSGLI Benefits
Form due to the member's physical or mental incapacity, the form must be
signed by the member's guardian; if none, the member's agent or attorney
acting under a valid Power of Attorney; if none, the member's military
trustee.

\(iii\) If a member suffered a scheduled loss as a direct result of the
traumatic injury, survived seven full days from the date of the
traumatic event, and then died before the maximum benefit for which the
service member qualifies is paid, the beneficiary or beneficiaries of
the member's Servicemembers' Group Life Insurance policy should complete
an Application for TSGLI Benefits Form.

\(2\) If a member seeks traumatic injury protection benefits for a
scheduled loss occurring after submission of a completed Application for
TSGLI Benefits Form for a different scheduled loss, the member must
submit a completed Application for TSGLI Benefits Form for the new
scheduled loss and for each scheduled loss that occurs thereafter and
for each increment of a scheduled loss that occurs thereafter. For
example, if a member seeks traumatic injury protection benefits for a
scheduled loss due to coma from traumatic injury and/or the inability to
carry out activities of daily living due to traumatic brain injury
(§9.20(f)(17)), or the inability to carry out activities of daily living
due to loss directly resulting from a traumatic injury other than an
injury to the brain (§9.20(f)(19)), a completed Application for TSGLI
Benefits Form must be submitted for each increment of time for which
TSGLI is payable. Also, for example, if a service member suffers a
scheduled loss due to a coma, a completed Application for TSGLI Benefits
Form should be filed after the 15th consecutive day that the member is
in the coma, for which \$25,000 is payable. If the member remains in a
coma for another 15 days, another completed Application for TSGLI
Benefits Form should be submitted and another \$25,000 will be paid.

\(i\) *How does a member or beneficiary appeal an adverse eligibility
determination?*

\(1\) Notice of a decision regarding a member's eligibility for
traumatic injury protection benefits will include an explanation of the
procedure for obtaining review of the decision. An appeal of an
eligibility determination, such as whether the loss occurred within 365
days of the traumatic injury, whether the injury was self-inflicted or
whether a loss of hearing was total and permanent, must be in writing.
An appeal must be submitted by a member or a member's legal
representative or by the beneficiary or the beneficiary's legal
representative, within one year of the date of a denial of eligibility,
to the office of the uniformed service identified in the decision
regarding the member's eligibility for the benefit.

\(2\) An appeal regarding whether a member was insured under
Servicemembers' Group Life Insurance when the traumatic injury was
sustained must be in writing. An appeal must be submitted by a member or
a member's legal representative or by the beneficiary or the
beneficiary's legal representative within one year of the date of a
denial of eligibility to the Office of Servicemembers' Group Life
Insurance.

\(3\) Nothing in this section precludes a member from pursuing legal
remedies under 38 U.S.C. 1975 and 38 CFR 9.13.

\(j\) *Who will be paid the traumatic injury protection benefit?* The
injured member who suffered a scheduled loss will be paid the traumatic
injury protection benefit in accordance with title 38 U.S.C. 1980A
except under the following circumstances:

\(1\) If a member is legally incapacitated, the member's guardian or
agent or attorney acting under a valid Power of Attorney will be paid
the benefit on behalf of the member.

\(2\) If no guardian, agent, or attorney is authorized to act as the
member's legal representative, a military trustee who has been appointed
under the authority of 37 U.S.C. 602 will be paid the benefit on behalf
of the member. The military trustee will report the receipt of the
traumatic injury benefit payment and any disbursements from that payment
to the Department of Defense.

\(3\) If a member dies before payment is made, the beneficiary or
beneficiaries who will be paid the benefit will be determined in
accordance with 38 U.S.C. 1970(a). (Authority: 37 U.S.C. 602, 603; 38
U.S.C. 501(a), 1980A)

\(k\) The Traumatic Servicemembers' Group Life Insurance program will be
administered in accordance with this rule, except to the extent that any
regulatory provision is inconsistent with subsequently enacted
applicable law.

(The Office of Management and Budget has approved the information
collection requirements in this section under control number 2900-0671.)

\[70 FR 75946, Dec. 22, 2005, as amended at 72 FR 10365, Mar. 8, 2007;
73 FR 71930, Nov. 26, 2008\]

**Supplement *Highlights* references:** 17(1), 19(1), 20(1).

*End of Part 9*