Citation Nr: 1606550 Decision Date: 02/22/16 Archive Date: 03/01/16 DOCKET NO. 14-24 713A ) DATE ) ) On appeal from the Department of Veterans Affairs Medical Center in Orlando, Florida THE ISSUE Entitlement to payment or reimbursement of medical expenses incurred at the Flagler Florida Hospital for medical treatment on February 22, 2014. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Brandon A. Williams, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1970 until June 1974. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from an April 2014 decision of the Orlando, Florida Veteran's Affairs Medical Center (VAMC), which disapproved a claim for payment of unauthorized care at Flagler Florida Hospital for medical treatment on February 22, 2014. FINDINGS OF FACT 1. The Veteran received emergency services at Venice Regional Medical Center from Flagler Florida Hospital for medical treatment on February 22, 2014, for a nonservice-connected disability. 2. The treatment was 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; an attempt to use a VA or other Federal facility/provider was not considered reasonable by the Veteran (a prudent layperson). CONCLUSION OF LAW The criteria for payment or reimbursement of medical expenses incurred at Flagler Florida Hospital for medical treatment on February 22, 2014, have been met. 38 U.S.C.A. §§ 1725, 5107 (West 2014); 38 C.F.R. §§ 3.102, 17.1000, 17.1001, 17.1002 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION In this decision, the Board grants reimbursement, which represents a complete grant of the benefit sought on appeal. Thus, there is no need to discuss whether VA has complied with its duties to notify and assist found at 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. § 3.159. Legal Criteria The Veteran is seeking entitlement to reimbursement or payment for medical expenses incurred at Flagler Florida Hospital for medical treatment on February 22, 2014. As the Veteran was treated for a non-service connected condition, 38 U.S.C.A. § 1725 and 38 C.F.R. §§ 17.1000-1002 applies to the issue of entitlement to medical reimbursement for emergency treatment. To be eligible for reimbursement under this authority the Veteran has to satisfy all of the following conditions: (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 beforehand 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) 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; (e) The veteran is financially liable to the provider of emergency treatment for that treatment; (f) 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); (g) 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; (h) The veteran is not eligible for reimbursement under 38 U.S.C.A. § 1728 for the emergency treatment provided (38 U.S.C.A. § 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 (a)-(h). Under the statute, in order to be entitled to payment or reimbursement for medical expenses incurred, all of the listed requirements must be met; therefore, the claim must be denied if there is a failure to satisfy any single criterion. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision means that all of the conditions listed in the provision must be met). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the claim on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. In this case, a review of the record indicates that the Veteran does satisfy the requisite criterion set forth above, and thus reimbursement under the provisions of 38 U.S.C.A. § 1725 and 38 C.F.R. § 17.1002 is granted. See 38 U.S.C.A. § 1725(b); 38 C.F.R. § 17.1002(c). Specifically, the Veteran contends that three weeks after a colonoscopy administered by VA, he experienced bleeding from his rectum. The Veteran's medical condition prompted him to call VA and inform them of his condition. During the phone call with VA, the Veteran was informed that he was not receiving authorization for VA payment; however, he was encouraged to request the local facility to contact the nearest VAMC for transfer arrangements upon stabilization. (See February 2014 Nursing Telephone Encounter Note). The claims folder further reflects that VA considered the Veteran's condition to be urgent and recommended he be seen at an emergency room. (See February 2014 Nursing Telephone Encounter Note). The Veteran subsequently had his wife take him to Flagler Florida Hospital for emergency treatment. The claims folder reflects that the Veteran had rectal bleeding that fluctuated in intensity. (See February 2014Emergency Room record). The Veteran contends that the nearest VAMC located in Orlando, Florida is approximately 80 miles from the Veteran's residence. (See February 2015 Appellant's Brief). The Board has no reason to doubt the sincerity of the Veteran that he believed his condition at the time was hazardous to his health. As mentioned above, the Veteran has recently undergone a colonoscopy and was experiencing rectal bleeding. Furthermore, the claims folder reflects that prior to the Veteran's emergency treatment, VA considered his condition to be urgent. Hence, it was reasonable for the Veteran to have expected that a delay in seeking immediate medical attention would have been hazardous to his health. See 38 C.F.R. § 17.1002 (b). Moreover, the Board finds that given VA's recommendation for emergency room treatment, it was reasonable for the Veteran, a prudent layperson, to assume that driving the extra distance to the VA medical center was not feasible. See 38 C.F.R. § 17.1002 (c). The emergency services were provided in a hospital emergency department. See 38 C.F.R. § 17.1002 (a). 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. See 38 C.F.R. § 17.1002 (d). The Veteran was financially liable to the provider of emergency treatment for that treatment. See 38 C.F.R. § 17.1002 (e). The Veteran has no coverage under a health-plan contract for payment or reimbursement, in whole or in part, for the emergency treatment. See 38 C.F.R. § 17.1002 (f). The Veteran was not eligible for reimbursement under 38 U.S.C.A. § 1728 for the emergency treatment provided. See 38 C.F.R. § 17.1002 (h). The Board notes that the Veteran is not seeking reimbursement for treatment that was for an accident or work related injury; consequently, 38 C.F.R. § 17.1002(g) is not applicable. Accordingly, for the reasons stated above, reimbursement for medical treatment at Flagler Florida Hospital for medical treatment on February 22, 2014, under the provisions of 38 U.S.C.A. § 1725 and 38 C.F.R. § 17.1002, is warranted. ORDER Entitlement to payment or reimbursement of medical expenses incurred at the Flagler Florida Hospital for medical treatment on February 22, 2014 is granted. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs