Citation Nr: 1317776 Decision Date: 05/31/13 Archive Date: 06/06/13 DOCKET NO. 10-11 221A ) DATE ) ) On appeal from the Department of Veterans Affairs Nebraska-Western Iowa Health Care System THE ISSUE Entitlement to payment of, or reimbursement for, unauthorized private medical expenses associated with the Veteran's emergency room treatment at St. Francis Medical Center in Grand Island, Nebraska, on March 26, 2010. [The issue of entitlement to special monthly pension benefits at the housebound rate will be addressed in a separate decision with a separate docket number to be issued concurrently.] REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers ATTORNEY FOR THE BOARD Elizabeth Jalley, Counsel INTRODUCTION The Veteran served on active duty from July 1974 to December 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2010 determination by the Department of Veterans Affairs Nebraska-Western Iowa Health Care System. In his September 2010 substantive appeal, the appellant requested a hearing at a local VA office before a Member of the Board. He was scheduled for a Board hearing for November 2012, and he was sent a notice letter in October 2012. The appellant did not report for this hearing. He has neither requested a new hearing nor shown good cause for his failure to report to the prior hearing. Therefore, his hearing request is deemed withdrawn. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran has claimed entitlement to payment of, or reimbursement for, unauthorized private medical expenses associated with his emergency room treatment at St. Francis Medical Center in Grand Island, Nebraska, on March 26, 2010. The Veteran has submitted bills from St. Francis Medical Center totaling $1210.70 and from Grand Island Radiology Associates totaling $40.00. Reimbursement claims that were submitted to VA were denied in April 2010. In order to obtain reimbursement for non-VA emergency services furnished to a veteran for non-service-connected conditions, all of the criteria in 38 U.S.C. § 1725 and its implementing regulations, C.F.R. §§ 17.100-17.1008, must be satisfied: (a) The emergency services were provided in a hospital emergency department or a similar facility held out as providing emergency care to the public. (b) The claim for payment or reimbursement for the initial evaluation and treatment is for a condition of such a nature that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health (this standard would be met if there were an emergency medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part); (c) A VA or other Federal facility/provider was not feasibly available and an attempt to use them before hand would not have been considered reasonable by a prudent layperson (as an example, these conditions would be met by evidence establishing that a veteran was brought to a hospital in an ambulance and the ambulance personnel determined that the nearest available appropriate level of care was at a non-VA medical center); (d) The claim for payment or reimbursement for any medical care beyond the initial emergency evaluation and treatment is for a continued medical emergency of such a nature that the veteran could not have been safely transferred to a VA or other Federal facility; (e) At the time the emergency treatment was furnished, the veteran was enrolled in the VA health care system and had received medical services under authority of 38 U.S.C. Chapter 17 within the 24-month period preceding the furnishing of such emergency treatment; (f) The veteran is financially liable to the provider of emergency treatment for that treatment; (g) The veteran has no coverage under a health-plan contract for payment or reimbursement, in whole or in part, for the emergency treatment (this condition cannot be met if the veteran has coverage under a health-plan contract but payment is barred because of a failure by the veteran or provider to comply with the provisions of that health-plan contract, e.g., failure to submit a bill or medical records within specified time limits, or failure to exhaust appeals of the denial of payment); (h) If the condition for which the emergency treatment was furnished was caused by an accident or work-related injury, the claimant has exhausted without success all claims and remedies reasonably available to the veteran or provider against a third party for payment of such treatment; and the veteran has no contractual or legal recourse against a third party that could reasonably be pursued for the purpose of extinguishing, in whole or in part, the veteran's liability to the provider; and (i) The veteran is not eligible for reimbursement under 38 U.S.C. § 1728 for the emergency treatment provided (38 (U.S.C. 1728 authorizes VA payment or reimbursement for emergency treatment to a limited group of veterans, primarily those who receive emergency treatment for a service-connected disability). See 38 C.F.R. § 17.1002 (2012). Before a decision may be made on this claim, the Board requires clarification of whether element (g) is satisfied. The record reflects that the Veteran only has Medicare Part A coverage, but it is unclear which, if any, of the medical expenses at issue were eligible for reimbursement under Medicare Part A. Before a decision may be made on this claim, VA must obtain documentation of any St. Francis Medical Center and Grand Island Radiology Associates medical bills that were incurred by the Veteran in connection with his March 26, 2010, emergency room treatment, to include any bills that were paid by Medicare Part A and any bills for which payment was denied. The findings should be included in the claims folder for review. Accordingly, the case is REMANDED for the following action: 1. Obtain documentation of any St. Francis Medical Center and Grand Island Radiology Associates medical bills that were incurred by the Veteran in connection with his March 26, 2010, emergency room treatment, to include any bills that were paid by Medicare Part A and any bills for which payment was denied. The findings should be included in the claims folder for review. 2. After the development requested above has been completed, again review the record. If any benefit sought on appeal remains denied, the appellant and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).