Citation Nr: 18147455 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 16-11 124A DATE: November 5, 2018 ORDER Payment or reimbursement of medical expenses incurred on December 30, 2013, at Elk Regional Health Center (ERHC) is denied. Payment or reimbursement of medical transportation expenses incurred on February 1, 2014, from Ridgway Ambulance Corporation (RAC) is denied. Payment or reimbursement of medical expenses incurred on February 5, 2014, at ERHC is denied. FINDINGS OF FACT 1. A claim was submitted to the Department of Veterans Affairs (VA) for the Veteran’s December 30, 2013, treatment, for payment of services in the amount of $32; a letter from VA dated January 19, 2014, informed the Veteran that his claim for reimbursement had been denied due to a lack of medical records documenting the claimed treatment; and he did not respond to the letter within a year. 2. The earliest additional claim for payment or reimbursement of medical expenses incurred at ERHC for Veteran’s December 30, 2013, treatment, as well as the earliest claims for his February 1, 2014, treatment with RAC or February 5, 2014, treatment at ERHC, filed by him or any other claimant, was not within 90 days of any such treatment dates, or a date on which he exhausted action to obtain payment or reimbursement for the treatment from a third party. CONCLUSIONS OF LAW 1. The criteria for payment or reimbursement of medical expenses incurred on December 30, 2013, at ERHC have not been met. 38 U.S.C. §§ 1725, 5107, 7105; 38 C.F.R. §§ 17.1000-1008, 20.302, 20.1103. 2. The criteria for payment or reimbursement of medical expenses incurred on February 1, 2014, from RAC have not been met. 38 U.S.C. §§ 1725, 5107; 38 C.F.R. §§ 17.1000-1008. 3. The criteria for payment or reimbursement of medical expenses incurred on February 5, 2014, at ERHC have not been met. 38 U.S.C. §§ 1725, 5107; 38 C.F.R. §§ 17.1000-1008. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 2006 to March 2008. This appeal is before the Board of Veterans’ Appeals (Board) from October and December 2015 decisions of a VA Medical Center. The Veteran seeks payment or reimbursement of expenses incurred for medical treatment on December 30, 2013, and February 5, 2014, at ERHC, and for transportation expenses incurred from RAC on February 1, 2014. Initially, the Board notes that in a June 2015 decision the Veteran was granted an increased rating to 100 percent for a service-connected psychiatric disability, effective May 30, 2015; he was at that same time determined by the agency of original jurisdiction (AOJ) to have had a permanent and total disability. However, the Veteran was not permanently and totally disabled due to any service-connected disability or disabilities in December 2013 or February 2014; also, his treatment at those times has not been shown to be for any service-connected disability or for any disorder that was aggravated by any service-connected disability. Likewise, the Veteran’s treatment was not for any injury or illness contracted in the course of a rehabilitative program. Consequently, the Veteran is not eligible for payment or reimbursement under 38 U.S.C. § 1728 in this case. See 38 U.S.C. § 1728; 38 C.F.R. § 17.120. Nonetheless, the Veterans Millennium Health Care and Benefits Act also provides general authority for reimbursement for the reasonable value of emergency treatment furnished in a non-VA facility to those Veterans who are active VA health-care participants (i.e., enrolled in the annual patient enrollment system and recipients of a VA hospital, nursing home, or domiciliary care under such system within the last 24-month period) and who are personally liable for such non-VA treatment and not eligible for reimbursement under the provisions of 38 U.S.C. § 1728. 38 U.S.C. § 1725; 38 C.F.R. §§ 17.1000-1008. Pursuant to 38 U.S.C. § 1725, under certain circumstances, VA shall reimburse a veteran for the reasonable value of emergency treatment furnished the veteran in a non-Department facility. VA regulations at 38 C.F.R. §§ 17.1000 through 17.1008 constitute the requirements under 38 U.S.C. § 1725 that govern VA payment or reimbursement for non-VA emergency services furnished to a veteran for nonservice-connected conditions. 38 C.F.R. §§ 17.1000. Payment or reimbursement under 38 U.S.C. § 1725 for ambulance services, including air ambulance services, may be made for transporting a veteran to a facility where payment or reimbursement is authorized under 38 U.S.C. § 1725 for emergency treatment provided at a non-VA facility if certain other conditions are met. 38 C.F.R. § 17.1003(a). These other conditions are listed under 38 C.F.R. § 17.1003. To obtain payment or reimbursement for emergency treatment under 38 U.S.C. 1725, a claimant must submit to the VA medical facility of jurisdiction a completed standard billing form (such as a UB92 or a HCFA 1500). 38 C.F.R. § 17.1004(b). For purposes relevant to the facts of this case, to receive payment or reimbursement for emergency services under 38 U.S.C. § 1725, a claimant must file a claim within 90 days after the latest of the following: the date that the veteran was discharged from the facility that furnished the emergency treatment; or the date the veteran finally exhausted, without success, action to obtain payment or reimbursement for the treatment from a third party. 38 C.F.R. § 17.1004(d). If after reviewing a claim the decisionmaker determines that additional information is needed regarding the claim, such official will contact the claimant in writing and request additional information. The additional information must be submitted to the decisionmaker within 30 days of receipt of the request or the claim will be treated as abandoned, except that if the claimant within the 30-day period requests in writing additional time, the time-period for submission of the information may be extended as reasonably necessary for the requested information to be obtained. 38 C.F.R. § 17.1004(e). The record reflects that the Veteran received treatment at ERHC on December 30, 2013, for symptoms of chest tightness and wheezing, and on February 5, 2014, for a right ankle injury after slipping on ice. It further reflects that he was billed for services from RAC occurring on February 1, 2014; it is unclear what the ambulance service bill was related to, and there are no treatment records in connection with the bill. It appears that initially one timely claim was submitted to VA for the Veteran’s December 30, 2013, treatment, for payment of services in the amount of $32; a letter dated January 19, 2014, sent by the AOJ to the Veteran at the address listed on his health insurance claim form for the December 30 treatment (as well as on the forms for the February 2014 treatment), informed him that his claim for reimbursement had been denied due to a lack of medical records documenting the claimed treatment, which were listed in the letter. The record does not contain any response to the letter within a year, and the Veteran has not asserted that he sent any such response. Therefore, that determination by the AOJ is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. In September 2015, VA received both another health insurance claim form for additional services from ERHC on December 30, 2013, as well as a form for services from ERHC on February 5, 2014. In November 2015, VA received a health insurance claim form for services from RAC on February 1, 2015. In this case, the Veteran’s claims must be denied. The Veteran has not asserted that he personally filed his September 2015 reimbursement claims until after the 90-day limit for such claims. He has furthermore not asserted, and the record does not reflect, that he attempted, without success, action to obtain payment or reimbursement for the treatment from a third party 90 days or fewer before his any reimbursement claim was filed with VA. The Board acknowledges the Veteran’s assertions, as reflected in statements received in February and March 2016, that, prior to each visit to ERHC, he contacted VA and explained that he was not able to get to a VA facility, and was told to visit the nearest medical facility and tell them to bill VA; that he gave ERHC all his VA information; and that he assumed that VA was billed, as he did not receive a bill for the services. He asserts that he did not realize that the bills had not been submitted to VA until he moved back to California, when a credit report showed the amounts that had been turned over to collections. He further asserts that he contacted ERHC and asked why VA had not been billed for his treatment, but did not receive any helpful information. The record does not contain any explanation of why the Veteran did not receive his bills from ERHC until they were well-past due, and the Veteran has not indicated what response he was given when he asked them. However, the record does not reflect that either he or ERHC submitted timely claims for payment to VA. The Board is bound by VA regulations regarding limitations on reimbursement, including time limitations for filing claims. See 38 U.S.C. § 1725(c)(1)(B); 38 C.F.R. § 17.1004(d). The record reflects that the Veteran did not meet the basic filing requirements for any of his medical reimbursement claims under 38 C.F.R. § 17.1004—specifically, regarding the time limitations for filing claims—and the Veteran has provided no evidence or argument to the contrary. Accordingly, payment or reimbursement of medical expenses incurred on December 30, 2013, and February 5, 2014, at ERHC, and February 1, at RAC, must be denied. See 38 U.S.C. § 5107. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Andrew Mack, Counsel