Citation Nr: 18159366
Decision Date: 12/19/18	Archive Date: 12/18/18

DOCKET NO. 16-35 270A
DATE:	December 19, 2018
REMANDED
The issue of entitlement to payment or reimbursement for unauthorized private medical expenses incurred at Mercy Medical Center from December 29-30, 2010, is remanded.
REASONS FOR REMAND
This case must be remanded to allow the Agency of Original Jurisdiction (AOJ) to properly adjudicate the Veteran’s claim in the first instance.  The AOJ must make specific factual findings, as directed below, which are presently not addressed.
The January 2012 determination on appeal also appears to have denied the Veteran’s claim on an inaccurate basis, specifically that his claim was untimely filed and that he had insurance coverage at the time of the treatment.  While the AOJ appears to have conceded these points in the Veteran’s favor in a May 2016 statement of the case, it did not correct the findings in the original determination nor properly adjudicate the appeal under 38 U.S.C. § 1725.
The matter is REMANDED for the following action:
Readjudicate the appeal under the provisions of 38 U.S.C. § 1725 and 38 C.F.R. §§ 17.1000-17.1008.  Specific findings AND DISCUSSION of the evidence should include:
(a.) Whether the services at issue were provided in a hospital emergency department or similar facility held out as providing emergency care to the public; 
(b.) Whether the treatment at issue was for a condition 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; and 
(c.) Whether a VA or other Federal facility/provider that VA has an agreement with to furnish health care services for veterans was reasonably available.
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If the benefits sought on appeal are not granted to the appellant's satisfaction, he and his representative should be provided with a supplemental statement of the case.  An appropriate period should be allowed for response.
 
Vito A. Clementi
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Christopher Murray, Counsel