KEVIN STRINGER RYAN O'NEILL; JOAQUIN MARTINEZ; CHRISTOPHER ANDERSON; and WILLIAM LEGER, III, individually and on behalf of all others similarly situated, Plaintiffs,
THE UNITED STATES OF AMERICA, Defendant.
ORDER DENYING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT AS TO PLAINTIFF RYAN O'NEILL AND ORDER FOR REMAND
RICHARD P. MATSCH, Senior District Judge.
On September 12, 2011, Ryan O'Neill submitted an application for benefits under the Servicemembers' Group Life Insurance Traumatic Injury Protection Program ("TSGLI"). He was informed of the denial by a letter dated September 28, 2011, from the Office of Servicemember Group Life Insurance (OSGLI), saying:
Because medical documentation does not support your inability to perform two or more ADLs for at least 30 consecutive days, your branch of service could not approve your claim.
(Def.'s Ex. 1 at 000001-3).
That letter advised O'Neill of his right to appeal to the U.S. Army Human Resources Command within one year of denial which appeal should contain "The reason why you disagree with our determination." ( Id. at 000002). Rather than filing that appeal, O'Neill joined with other plaintiffs in filing this civil action for judicial review under 38 U.S.C. § 1975. That statute provides
The district courts of the United States shall have original jurisdiction of any civil action or claim against the United States founded upon this subchapter [38 USC § 1965 et seq.].
Paragraph 4 of the complaint alleges:
This class action is brought on behalf of all service members of the Army who submitted claims for disability benefits under the Activities of Daily Living provision of the Servicemembers' Group Life Insurance Traumatic Injury Protection Program and received an adverse decision stating that a member's loss did not meet the requirements for a loss under TSGLI.
Paragraphs 22 and 23 allege:
Furthermore, the Army is uniformly violating its own guidelines for denying claims by failing to provide Loss Codes that adequately advise the applicant of the reason for a denial. Instead, the denial letter simply states in each case that "the documentation provided did not indicate that you meet the TSGLI standards for loss of Activities of Daily Living (ADL)." These denial letters are clearly "boilerplate" letters that provide no substantive information to the applicant, only miming Reason 3 of the 17 Loss Codes, and does not address the medical professional's certification of qualification under the ADL criteria. (Example of Denial letter - Exhibit C). In addition, the Defendant is obligated to notify unsuccessful applicants of their right to file suit, but fails to do so, leaving the class members with no understanding that they have legal recourse.
Despite its legal and contractual obligations, the Army has standardized the practice of denying ADL claims in a manner that is arbitrary, unsupported by its own guidelines, and contrary to law.
In 2005 Congress enacted an addition to the Servicemembers' Group Life Insurance
(SGLI) program to provide benefits for losses caused by a "traumatic injury."
Administration of SGLI and TSGLI benefits is within the responsibilities of the Department of Veterans Affairs (VA). The authorizing legislation is codified at 38 U.S.C. § 1980A and the VA's regulations are at 38 C.F.R. § 9.20. The statute provides for payment of defined benefits for "qualifying losses" including the inability to carry out specified activities of daily living (ADLs) resulting from traumatic injury to the brain. 38 U.S.C. § 1980A(b)(1)(H). The VA's regulation expands the coverage to include other traumatic injuries and establishes schedules of payments for specific injuries with additional payments for the inability to perform at least two ADLs for consecutive days which differ depending upon whether the injury involves the brain. The maximum ...