Citation Nr: 18153994 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 16-25 878 DATE: November 29, 2018 REMANDED Entitlement to payment or reimbursement for unauthorized medical expenses incurred at Ocala Regional Medical Center (ORMC) from May 22, 2015 through June 24, 2015, is remanded. REASONS FOR REMAND The Veteran had active duty service from June 1975 to June 1978, and October 1978 to November 1980. This matter appears to come before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 letter of determination by a Department of Veterans Affairs (VA) Medical Center, although the Board notes that there are numerous subsequent letters of determination from November 2015, December 2015, and February 2016 involving medical expenses stemming from the noted period above. From the record, it appears that the Veteran was involved in a motor vehicle accident on May 22, 2015, in which he suffered significant trauma injuries to his back, ribs, and lungs. It appears that the Veteran was treated by ORMC from May 22, 2015 until he was discharged on approximately June 12, 2015; it is unclear, however, why the Veteran had referenced the period from June 12, 2015 through June 24, 2015 in this case. Initially, in the August 2016 letter of determination, the Agency of Original Jurisdiction (AOJ) denied the Veteran’s claim because he had third-party automobile insurance, although it was later determined that he was not covered by that insurance policy. In any regard, merely having third-party insurance that does not completely extinguish all financial liability is not a bar to payment or reimbursement of unauthorized medical expenses under 38 U.S.C. § 1725. See 38 C.F.R. § 17.1002; Staab v. McDonald, 28 Vet. App. 50 (2016). It appears that the November and December 2015 letters of determination continued to deny the Veteran’s claims for various reasons, to include not being timely filed claims; the Board notes that there was clearly a timely filed claim in this case, as the AOJ denied the claim within 90 days of the Veteran’s discharge from the facility, and this appeal stems from the denial of that timely claim. In the January 2016 statement of the case, the AOJ denied the claim on the basis that the Veteran was stable for transfer to VA facilities on June 1, 2015; underlying this is a referenced VA physician’s undated “determination” that the Veteran was stable for transfer on that date after reviewing the claims file. The Board reflects that such “determination” by the VA physician does not appear to have been put in writing, or if it was, such medical opinion was not associated with the claims file. Subsequent February 2016 letters of determination indicated that the Veteran’s claims related to this period were being denied because VA facilities were feasibly available. Based on the above evidence, the scope of this claim remains unclear and adjudication of the claim at this time would be premature. First, based on the finding of stability, it appears that the Veteran’s claim for payment or reimbursement of medical expenses has been at least partially awarded for the period of May 22, 2015 through June 1, 2015. If such payment/reimbursement has been authorized, it is unclear what period such has been authorized for based on the record at this time. In any event, the record does not contain any medical opinion regarding stability for transfer that the AOJ references in its January 2016 statement of the case. Consequently, as it appears that there is missing pertinent VA records in this case, a remand is necessary in order to obtain any medical opinion that the AOJ has obtained in conjunction with adjudication of this appeal. See 38 U.S.C. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016); Bell v. Derwinski, 2 Vet. App. 611 (1992). On remand, the AOJ should complete any and all other development necessary to properly adjudication this claim, and should endeavor to be clear about what, if any, period of treatment the Veteran has been authorized payment or reimbursement of medical expenses in this case. The matter is REMANDED for the following action: 1. Associate with the claims file the VA physician’s written medical determination referenced in the January 2016 statement of case. 2. Ask the Veteran to submit any evidence regarding out-of-pocket medical expenses that have not covered by his third-party insurance that he is seeking payment or reimbursement for in this case. 3. After attempting to obtain the above, the AOJ should complete any and all appropriate development necessary to properly adjudicate the claim on appeal. 4. Following completion of the above development, the AOJ should review the claims file and readjudicate the Veteran’s claim for payment or reimbursement for unauthorized medical expenses incurred at Ocala Regional Medical Center (ORMC) from May 22, 2015 through June 24, 2015. The AOJ should clearly delineate what, if any, periods of medical treatment during that period have previously been authorized by the AOJ for payment or reimbursement of medical expenses. For any period of medical treatment during the period that the AOJ continues denial of authorization of payment or reimbursement of medical expenses, the reasons for such denial must be clearly documented and explained. If any benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Peters, Counsel