Citation Nr: 18158207
Decision Date: 12/14/18	Archive Date: 12/14/18

DOCKET NO. 16-35 304A
DATE:	December 14, 2018
ORDER
Entitlement to reimbursement or payment of medical expenses incurred at a private hospital on January 4, 2016, is granted.
FINDINGS OF FACT
1. The medical services provided at a private hospital on January 4, 2016, were rendered in a medical emergency 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.
2. Resolving all reasonable doubt in the Veteran’s favor, the evidence of record suggests that 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.
CONCLUSION OF LAW
The criteria for entitlement to reimbursement of medical expenses incurred at a private hospital on January 4, 2016, have been met.  38 U.S.C. §§ 1703, 1725, 1728 (2012); 38 C.F.R. §§ 17.120-17.121 (2018).
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REASONS AND BASES FOR FINDINGS AND CONCLUSION
The Veteran had active naval service from September 1983 to September 1987.
This case comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 administrative decision issued by the Department of Veterans Affairs (VA) Medical Center in Gainesville, Florida.  
Medical reimbursement
The Veteran is seeking reimbursement for medical expenses incurred at a private hospital on January 4, 2016.  He contends that he initially went to the VA facility in Jacksonville, Florida.  He contends that someone at the VA facility informed him that there was not a doctor present that could treat him.  The Veteran stated that he could no longer deal with his knee pain, so that he needed to seek immediate treatment.  The claim was denied on the basis of feasibility of a VA facility, and that the care was non-emergent.
Medical treatment records note that upon arrival to the emergency department the Veteran had symptoms such as pain and swelling in his left knee.  He reported that there was no injury to his knee to cause the pain.  The private medical record note that the Veteran’s pain onset two days prior to the Veteran’s emergency room visit.  However, the private medical record notes that the Veteran’s condition was an emergency condition due to the acute onset of symptoms.
Moreover, as noted above, the Veteran asserted that he initially went to a VA facility in Jacksonville, Florida.  That he was told that the facility did not have a doctor that could treat him.  VA originally denied the claim, in part, due to feasibility of a VA facility.  Specifically, noting that a VA facility in Jacksonville, Florida was open for patient care.  Indeed, VA stated that there was no documentation to indicate any attempt to access care at VA.
However, evidence addressing the Veteran’s lay statement, and documenting that the Veteran could have sought treatment at a VA facility in Jacksonville, Florida is lacking.  Indeed, it appears that the agency of original jurisdiction (AOJ) did not develop the Veteran’s claim file.  In that regard, the Veteran asserted that he sought treatment for his knee pain at a VA facility 3-days after his non-VA emergency room visit.  Further, there is evidence that the Veteran had previously sought VA treatment.  However, the Veteran’s file does not contain any VA treatment records. 
In light of the above facts, the Board finds that the Veteran’s symptoms were such that a prudent layperson would have reasonably expected that delay in seeking immediate medical attention would have been hazardous to life or health.  Further, given the AOJ’s failure to develop properly the Veteran’s claim and because there is evidence that would suggest that a VA facility in Jacksonville, Florida was not feasibly available to treat the Veteran, the Board finds it appropriate to simply resolve reasonable doubt in favor of the Veteran and grant payment or reimbursement of medical expenses incurred in connection with treatment provided at Baptist Medical Center on January 4, 2016.  
Accordingly, the Board finds that the evidence for and against the claim is at least in equipoise.  Therefore, reasonable doubt must be resolved in favor of the Veteran and entitlement to payment or reimbursement for unauthorized medical expenses incurred at Baptist Medical Center on January 4, 2016, is warranted. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 
 
 
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	I. Cannaday, Associate Counsel