Citation Nr: 18151983 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-19 297A DATE: November 20, 2018 ORDER Payment or reimbursement of medical expenses incurred at a private hospital in Hiawassee, Georgia on February 18, 2015 is denied. FINDINGS OF FACT 1. The Veteran served on active duty from August 1977 to June 1978. 2. The medical services provided at a private hospital on February 18, 2015, were not rendered in a medical emergency of such a nature that delay would have been hazardous to life or health, and the situation was not analogous to one where federal facilities were not feasibly available and an attempt to use them beforehand would not have been reasonable. CONCLUSION OF LAW The criteria for entitlement to reimbursement of medical expenses incurred at a private hospital in Hiawassee, Georgia on February 18, 2015, have not been met. 38 U.S.C. §§ 1703, 1725, 1728 (2012); 38 C.F.R. §§ 17.120-17.121 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran sought emergency treatment at a private hospital for a one-week history of elevated blood pressure on February 18, 2015. He seeks payment or reimbursement of the medical expenses incurred, and the claim was denied on the basis that VA facilities were feasibly available. VA is authorized to reimburse veterans for emergency medical treatment under 38 U.S.C. § 1725 and 38 U.S.C. § 1728. To be eligible for reimbursement under 38 U.S.C. § 1728, the treatment must have been for associated with a service-connected disability or the veteran must be a participant in a vocational rehabilitation program. 38 U.S.C. § 1728(a); 38 C.F.R. § 17.120. The Veteran is not service-connected for hypertension or involved in a vocational rehabilitation program with VA, and so he did not meet the criteria for payment of authorized or unauthorized medical expenses of 38 U.S.C. § 1728; thus, his claim for payment must be considered under criteria for determining entitlement under the Veterans Millennium Healthcare and Benefits Act (Act), 38 U.S.C. § 1725; 38 C.F.R. §§ 17.1000-17.1008. For coverage under 38 U.S.C. § 1725, a veteran must be an individual who is an active Department health-care participant who was personally liable for emergency treatment furnished the veteran in a non-Department facility. In claims involving payment or reimbursement by VA for medical expenses incurred as a result of treatment at a private facility, there are three possible theories of entitlement: (1) the private medical services were authorized by VA; (2) the veteran is entitled to payment or reimbursement for services not previously authorized that are related to or aggravated a service-connected disability; or (3) the veteran is entitled to payment or reimbursement for services not previously authorized relating to a nonservice-connected disability. 38 U.S.C. §§ 1703(a), 1725, 1728(a). Generally, the admission of a veteran to a non-VA hospital at VA expense must be authorized in advance. 38 C.F.R. § 17.54. Whether treatment was authorized is a factual, not a medical, determination. Similes v. Brown, 5 Vet. App. 555 (1994); 38 U.S.C. § 1703(a); 38 C.F.R. § 17.54. In the case of an emergency that existed at the time of admission, an authorization may be deemed a prior authorization if an application, whether formal or informal, by telephone, telegraph or other communication, made by the veteran or by others in his or her behalf, is made to VA within 72 hours after the hour of admission. 38 C.F.R. § 17.54. A veteran is an active Department health-care participant if the veteran is enrolled in the health care system established under § 1705(a) and received care within the 24-month period preceding the furnishing of such emergency treatment. 38 U.S.C. § 1725(b)(2). A veteran is personally liable for emergency treatment furnished the veteran in a non-Department facility if the veteran is financially liable to the provider of emergency treatment for that treatment; has no entitlement to care or services under a health-plan contract (determined, in the case of a health-plan contract as defined in §§ (f)(2)(B) or (f)(2)(C), without regard to any requirement or limitation relating to eligibility for care or services from any department or agency of the United States); has no other contractual or legal recourse against a third party that would, in whole, extinguish such liability to the provider; and is not eligible for reimbursement for medical care or services under § 1728. For purposes of this section, “emergency treatment” means medical care or services furnished, in the judgment of the Secretary, when Department or other Federal facilities are not feasibly available and an attempt to use them beforehand would not be reasonable; when such care or services are rendered in a medical emergency of such nature that a prudent layperson reasonably expects that delay in seeking immediate medical attention would be hazardous to life or health; and until such time as the veteran can be transferred safely to a Department facility or other Federal facility and such facility is capable of accepting such transfer; or such time as a Department facility or other Federal facility accepts such transfer if at the time the veteran could have been transferred safely to a Department facility or other Federal facility, no Department facility or other Federal facility agreed to accept such transfer; and the non-Department facility in which such medical care or services was furnished made and documented reasonable attempts to transfer the veteran to a Department facility or other Federal facility. 38 U.S.C. § 1725 (f)(1). The Veteran was triaged at the private emergency department at 16:51 on February 18, 2015, a Wednesday. Despite living in Georgia and having a VA clinic approximately 15 miles away in Blairsville, Georgia, according to a common internet map search, his VA treatment notes reflect that he was normally seen for medical care at the Franklin, North Carolina VA Community-Based Outpatient Clinic (CBOC), which was 36 miles away. Regardless, both clinics were closed at the time he arrived at the private hospital. Nevertheless, at the time of his emergency room visit, the Veteran reported elevated blood pressure readings for a week and private treatment records indicate that he checked his blood pressure at home. Thus, he knew for a week that his hypertension was uncontrolled. Moreover, the private treatment records show that the clinical examination revealed no abnormalities or deficits, including normal heart rate and rhythm and no respiratory distress. Thus, the private treatment records reveal no symptoms that suggest that the Veteran’s elevated blood pressure had become suddenly worse at the time he sought emergency treatment. Thus, there is no basis to conclude that he could not have waited until the next day to visit a VA outpatient clinic or the two hours to visit a VA hospital emergency department. Consequently, the preponderance of the evidence weighs against a finding that the Veteran’s symptoms on February 18, 2015 were of such severity that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect that the absence of immediate medical attention could result in placing the health of the person in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ. While the evidence establishes that the Veteran had elevated blood pressure readings which warranted medical treatment, the evidence also reflects that the symptoms did not require emergency care and that he had opportunity to seek non-emergent care for the symptoms. For these reasons, the claim of entitlement to payment or reimbursement of medical expenses incurred at a private hospital on February 18, 2015, is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. M. Schaefer, Counsel