Citation Nr: 1752626	
Decision Date: 11/16/17    Archive Date: 11/22/17

DOCKET NO.  14-08 732	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Medical Center in Columbus, Ohio


THE ISSUE

Entitlement to payment or reimbursement of medical expenses incurred at a private medical facility.  


REPRESENTATION

Veteran represented by:  The American Legion


ATTORNEY FOR THE BOARD

N. Robinson, Associate Counsel






INTRODUCTION

The Veteran served on active duty from October 1978 to May 1980.  This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2013 decision of the Department of Veterans Affairs (VA) Medical Center (MC) in Columbus, Ohio.   


FINDINGS OF FACT

1.  The Veteran was directed by his VA surgeon to seek immediate care for evaluation of a possible post-operative blood clot at a nearby private hospital emergency room. 

2.  It was not feasible for the Veteran to obtain this treatment from the VA or from another federal facility.


CONCLUSION OF LAW

The criteria for payment or reimbursement of unauthorized medical expenses incurred at a private medical facility have been met.  38 U.S.C. § 1725 (2012); 38 C.F.R. §§ 17.120, 17.121 (2017).


REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran in this case seeks reimbursement for care provided by non-VA facilities due to a concern for a post-operative blood clot.  For the following reasons, his claim shall be granted.

Payment for or reimbursement of emergency services for nonservice-connected conditions in non-VA facilities may be authorized under 38 U.S.C. § 1725.  This law and its associated regulations provide for payment or reimbursement of outside medical expenses if criteria are outlined in 38 C.F.R. § 17.1002 are met.  

The criterion in question is whether a VA or federal facility was feasibly available so that a prudent layperson would have reasonably considered using said federal facility.  

Here, the Veteran underwent knee surgery at a VA hospital in April 2012.   Subsequent to the surgery, his home nurse and physical therapist became worried that he had developed a post-operative blood clot.  The Veteran's spouse discussed this concern with the Veteran's VA surgeon who directed the Veteran to seek evaluation at the nearest emergency room.  The spouse asked the VA surgeon to specify exactly where they should go, and the surgeon directed them to a specific nearby private hospital.  The Board finds no reason to doubt the Veteran's credibility.  Because the Veteran has provided credible evidence establishing that he was advised to seek immediate attention at a private hospital's emergency room, the Board finds that seeking care at a VA hospital (against the wishes of his surgeon) was not feasible.  

In summary, the Board concludes that VA or other federal facilities were not feasibly available.  No other criterion has been raised as an issue.  Therefore, payment or reimbursement for the Veteran's treatment private hospital emergency room treatment on April 11, 2012 is warranted.


ORDER

Payment or reimbursement of unauthorized medical expenses incurred at a private medical facility on April 11, 2012 is granted.


____________________________________________
VICTORIA MOSHIASHWILI
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs