TSGLI Class Action Complaint

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF COLORADO

KEVIN STRINGER, RYAN O’NEILL, JOAQUIN MARTINEZ, CHRISTOPHER ANDERSON, AND WILLIAM LEGER III

individually and on behalf of all others similarly situated,

Plaintiffs, Civil Action No.
vs.
THE UNITED STATES OF AMERICA,
Defendant
________________________________________________________________
COMPLAINT AND JURY DEMAND
_______________________________________________________________
COME NOW Plaintiffs

Kevin Stringer, Ryan O’Neill, Joaquin Martinez, Christopher Anderson, and William Leger III,

on behalf of themselves and all others similarly situated, and allege as follows:

II. INTRODUCTION AND JURISDICTION
1. This is an action in contract for disability benefits that the United States Army failed to provide to service members under the terms of the Servicemembers’ Group Life Insurance Traumatic Injury Protection Program (hereafter “TGSLI”).
2. Plaintiffs bring this action both individually and on behalf of all others similarly situated against Defendant, The United States of America, based upon a failure of the United States Department of Army (hereafter “Army” or The Defendant) to pay benefits owed under the TGSLI program.
3. The Defendant is the United States of America, acting by and through the Department of the Army, an agency of the United States government.
4. 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.
5. This Court has jurisdiction over the parties under 38 USC 1975, as well as under the terms of the TSGLI program (Excerpts – Traumatic Injury Protection Under Servicemembers’ Group Life Insurance – A Procedural Guide – Exhibit A), as any member who receives an adverse TSGLI decision may obtain judicial review in any United States District Court of competent jurisdiction.
6. In addition, even if administrative reviews were required of TSGLI applicants prior to initiating a lawsuit, doing so would be futile because it is certain that an ADL claim will be summarily denied on appeal for the reasons stated herein.
7. Venue is proper in this district because at least one of the Plaintiffs is a resident of the State of Colorado.
II. FACTUAL ALLEGATIONS
8. All allegations contained in the previous paragraphs are incorporated herein by reference.
9. The Servicemembers’ Group Life Insurance Traumatic Injury Protection Program, also known as TSGLI, is a rider to the SGLI policy that provides a payment for service members injured as the result of a traumatic event.
10. TSGLI coverage was added to SGLI policies effective December 1, 2005. After Dec. 1, 2005, all service members covered by SGLI are eligible for TSGLI coverage, regardless of where their qualifying traumatic injury occurred. In addition, a retroactive program that covers service members who sustained a qualifying traumatic injury while supporting Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), or while on orders in a Combat Zone Tax Exclusion (CZTE) area from Oct. 7, 2001, through Nov. 30, 2005.
11. For service members who suffer a qualifying loss as a result of a traumatic injury event, the Defendant will pay between $25,000 and $100,000, depending on the qualifying loss.
12. The benefit is paid to the member, someone acting on the member’s behalf if the member is incompetent, or the members’ SGLI beneficiary if the member is deceased.
13. All members covered under SGLI who experienced a traumatic event that directly results in a traumatic injury causing a scheduled loss defined under the program are eligible for TSGLI payment.
14. Losses must meet the TSGLI standard in order to be eligible for a benefit payment. There are 9 categories of losses covered as follows:
1) Sensory Losses
2) Burns
3) Paralysis
4) Amputation
5) Limb Salvage
6) Facial Reconstruction
7) Activities of Daily Living
8 ) Inpatient Hospitalization
9) Coma/TBI combined with another injury
15. Activities of Daily Living (“ADL”) are defined as routine self-care activities that a person normally performs every day “without needing assistance”. (emphasis added) The six basic ADL are eating, bathing, dressing, toileting, transferring and continence.
16. A member will be considered eligible for a TSGLI benefit under the ADL provision if the member is unable to independently perform at least two of six ADL and the member’s inability lasts for at least 15 consecutive days for traumatic brain injury or at least 30 consecutive days for any other traumatic injury.
17. If a member submits an application for benefits, a medical professional must sign a Part B form to certify the medical information provided. In so doing, a medical professional certifies that the applicant meets the ADL criteria stated above.
18. The Plaintiffs and the proposed class members all have been diagnosed with traumatic injuries that include limitations of a minimum of 30 days for Activities of Daily Living.
19. An Army review board evaluated each Plaintiff’s and each proposed class member’s application for TSGLI benefits, and in each case, the application for ADL benefits was denied, even though a medical professional provided a Part B form affirming that the patient met the criteria for ADL coverage.
20. The Army’s TSGLI office systemically and regularly fails to certify claims for benefits under the ADL section of category of losses even though the Plaintiffs and class members meet the contractual and legal criteria with their applications.
21. The Army has uniformly denied each ADL claim for benefits (among other reasons) because it adds a criterion negating ADL coverage where there can be adaptive behavior to accomplish the activity, even though the adaptive standard is not contained in any manual or guidelines (Exhibit B).
22. 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.
23. 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
24. In a deliberate disregard of its legal obligation, the Army has denied coverage for the class members under the TGSLI, even though each class member met the legal requirements for the coverage, including certification from a treating physician that Activities of Daily Living of 30 days or more were limited.
25. The Plaintiffs and the proposed class members they seek to represent in this lawsuit are all service members, whose ADL claims were denied despite meeting the contractual criteria for payment of benefits, including the signing of the Part B medical form as required.
III. PARTIES
A. Kevin Stringer
26. All allegations contained in the previous paragraphs are incorporated herein by reference.
27. Plaintiff Kevin Stringer is a citizen of the United States and served in the Army at all times pertinent hereto.
28. At all times pertinent hereto, Mr. Stringer was eligible for TSGLI benefits through his status as a service member of the Army.
29. Mr. Stringer submitted an application for TSGLI benefits that included claims for ADL coverage. The ADL claim was supported by a Part B form signed by a medical professional, indicating that Mr. Stringer met the criteria for ADL benefits.
30. On September 29, 2011, Mr. Stringer received a letter denying him benefits, using the boilerplate language that he did not meet the TSGLI standards for loss of Activities of Daily Living.
31. In addition, the Army adds the standard of “adaptive measures” which, according to the TSGLI Procedure Manual, is not contained in any guidelines for consideration that the applicant has met the ADL criteria.
32. As a result of the Army’s breach of the TSGLI agreement, Mr. Stringer has suffered damages in the form of proscribed benefits due under the TSGLI.
B. Ryan O’Neill
33. All allegations contained in the previous paragraphs are incorporated herein by reference.
34. Plaintiff Ryan O’Neill is a citizen of the United States and served in the Army at all times pertinent hereto.
35. At all times pertinent hereto, Mr. O’Neill was eligible for TSGLI benefits through his status as a service member of the Army.
36. Mr. O’Neill submitted an application for TSGLI benefits that included claims for ADL coverage. The ADL claim was supported by a Part B form signed by a medical professional, indicating that Mr. O’Neill met the criteria for ADL benefits.
37. On September 29, 2011, Mr. O’Neill received a letter denying him benefits, using the boilerplate language that he did not meet the TSGLI standards for loss of Activities of Daily Living.
38. In addition, the Army adds the standard of “adaptive measures” which, according to the TSGLI Procedure Manual, is not contained in any guidelines for consideration that the applicant has met the ADL criteria.
39. As a result of the Army’s breach of the TSGLI agreement, Mr. O’Neill has suffered damages in the form of proscribed benefits due under the TSGLI.
C. Joaquin Martinez
40. All allegations contained in the previous paragraphs are incorporated herein by reference.
41. Plaintiff Joaquin Martinez is a citizen of the United States and served in the Army at all times pertinent hereto.
42. At all times pertinent hereto, Mr. Martinez was eligible for TSGLI benefits through his status as a service member of the Army.
43. Mr. Martinez submitted an application for TSGLI benefits that included claims for ADL coverage. The ADL claim was supported by a Part B form signed by a medical professional, indicating that Mr. Martinez met the criteria for ADL benefits.
44. Mr. Martinez received a letter denying him benefits, using the boilerplate language that he did not meet the TSGLI standards for loss of Activities of Daily Living.
45. In addition, the Army adds the standard of “adaptive measures”, which according to the TSGLI Procedure Manual, is not contained in any guidelines for consideration that the applicant has met the ADL criteria.
46. As a result of the Army’s breach of the TSGLI agreement, Mr. Martinez has suffered damages in the form of proscribed benefits due under the TSGLI.
D. Christopher Anderson
47. All allegations contained in the previous paragraphs are incorporated herein by reference.
48. Plaintiff Christopher Anderson is a citizen of the United States and served at all times pertinent hereto.
49. At all times pertinent hereto, Mr. Anderson was eligible for TSGLI benefits through his status as a service member of the Army.
50. Mr. Anderson submitted an application for TSGLI benefits that included claims for ADL coverage. The ADL claim was supported by a Part B form signed by a medical professional, indicating that Mr. Anderson met the criteria for ADL benefits.
51. On September 13, 2011, Mr. Anderson received a letter denying him benefits, using the boilerplate language that he did not meet the TSGLI standards for loss of Activities of Daily Living.
52. In addition, the Army adds the standard of “adaptive measures”, which according to the TSGLI Procedure Manual, is not contained in any guidelines for consideration that the applicant has met the ADL criteria.
53. As a result of the Army’s breach of the TSGLI agreement, Mr. Anderson has suffered damages in the form of proscribed benefits due under the TSGLI.
E. William Leger, III
54. All allegations contained in the previous paragraphs are incorporated herein by reference.
55. Plaintiff William Leger, III is a citizen of the United States and served in the Army at all times pertinent hereto.
56. At all times pertinent hereto, Mr. Leger was eligible for TSGLI benefits through his status as a service member of the Army.
57. Mr. Leger submitted an application for TSGLI benefits that included claims for ADL coverage. The ADL claim was supported by a Part B form signed by a medical professional, indicating that Mr. Leger met the criteria for ADL benefits.
58. On September 8, 2011, Mr. Leger received a letter denying him benefits, using the boilerplate language that he did not meet the TSGLI standards for loss of Activities of Daily Living.
59. In addition, the Army adds the standard of “adaptive measures”, which according to the TSGLI Procedure Manual, is not contained in any guidelines for consideration that the applicant has met the ADL criteria.
60. As a result of the Army’s breach of the TSGLI agreement, Mr. Leger has suffered damages in the form of proscribed benefits due under the TSGLI.
IV. CLAIMS FOR RELIEF
61. All allegations contained in the previous paragraphs are incorporated herein by reference.
62. The Plaintiffs herein assert claims for breach of contract that include:
a. Wrongfully failing to pay benefits under the TSGLI program, as outlined elsewhere herein.
b. Failing to identify reasons under the applicable guidelines, including omission of loss codes or adequate information upon which decisions are made;
c. Adding additional unauthorized criteria for ADL claims.
V. CLASS ACTION ALLEGATIONS
63. All allegations contained in the previous paragraphs are incorporated herein by reference.
64. This class action is brought on behalf of all members of the Army who submitted claims certified by a medical professional under the Servicemembers’ Group Life Insurance Traumatic Injury Protection Program that included Activities of Daily Living claims and who received an adverse decision that a member’s loss did not meet the requirements for a loss under TSGLI. Plaintiffs and the proposed class members have been denied the disability benefits as a result of the Army’s decision to disregard and circumvent the guidelines and requirements of the TSGLI
65. The Plaintiffs bring all claims herein individually and as an action for the class defined below, pursuant to Rule 23 of the Federal Rules of Civil Procedure. This action may properly be maintained as a class action, as it satisfies the numerosity, typicality, adequacy, predominance, and superiority requirements of F.R.C.P. Rule 23.
66. The class described above is so numerous that joinder of all individual members in one action would be impracticable. The exact size of the class and the identities of the individual members thereof are ascertainable through Defendant’s records. While the exact number of class members is not presently known to Plaintiffs and can only be ascertained through discovery, Plaintiffs believe that thousands of individuals are potential class members. The disposition of the individual claims of the respective class members through this class action will benefit both the parties and this Court.
67. There are questions of law common to the class, including the following:
a. Whether the Army has failed to apply the proper contractual and legal criteria to ADL claims.
b. Whether the Defendant is systemically and arbitrarily denying all ADL claims made under the TGSLI program.
c. The Plaintiffs retain the right to supplement the appropriate class periods for each count after preliminary discovery, and as is determined appropriate for each count based on state law and the facts of the case.
69. The Plaintiffs have the same interests in this matter as all other members of the class, and their claims are typical of all members of the class. The Plaintiffs’ claims are coincident with and not antagonistic to those of the other class members they seek to represent, as all class members have sustained damages arising out of the Defendant’s common course of conduct as outlined herein, and the damages of each class member were caused by the Defendant’s wrongful conduct.
69. The Plaintiffs will fairly, adequately, and vigorously represent and protect the interests of the members of the class and their interests do not conflict with the interests of the members of the class.
70. The Plaintiffs have retained counsel who are competent and experienced in the prosecution of class action litigation.
71. The questions of fact and law common to the class predominate over questions which may affect individual members.
72. A class action is superior to other available means for the fair and efficient adjudication of the claims of the class. This matter as a class action presents fewer management difficulties, conserves the resources of the parties and the court system, and would protect the rights of each member of the class. The Plaintiffs know of no difficulty to be encountered in the management of this action that would preclude its maintenance as a class action.
73. The common questions of law and fact involved in this action thus predominate over individual questions, if any. Class action treatment is the superior method for fair and efficient adjudication of this controversy because it permits numerous persons to prosecute their common claims jointly in a single forum and thus avoids unnecessary duplication and the potential for inconsistent rulings. A class action provides an efficient, manageable method to adjudicate fairly Plaintiffs’, and the proposed class members’, rights and obligations.
PRAYER FOR RELIEF
WHEREFORE, the Plaintiffs pray that this Court award the following relief:
a. Certify this action as a class action on behalf of the proposed Class;
b. Designate the Plaintiffs as representatives of the class;
c. Designate Plaintiffs’ Counsel of Record as Class Counsel;
d. Award Plaintiffs contractual benefits that are formulaic in nature in an amount, as to be determined at trial;
as to be determined at trial;
e. Award Plaintiffs interest, costs, and attorneys’ fees;
f. Grant such other relief as the Court deems just and proper.

Respectfully submitted,
By: /s/ L. Dan Rector ____