Citation Nr: 19119511
Decision Date: 03/19/19	Archive Date: 03/18/19

DOCKET NO. 15-31 580
DATE:	March 19, 2019

ORDER

Payment or reimbursement for that part of medical expenses for which the Veteran remains liable, other than any deductible, copayment, or similar payment owed under his third-party medical coverage, incurred due to non-VA medical care, from May 21, 2015, through May 22, 2015, at Mayo Clinic Health System (MCHS), is granted.

FINDINGS OF FACT

1. The Veteran received emergency services at MCHS from May 21, 2015, through May 22, 2015. 

2. The Veteran’s coverage under third-party insurance paid at least a portion of the private medical expenses incurred at MCHS from May 21, 2015, through May 22, 2015; and he is liable for the remainder of the costs.

CONCLUSION OF LAW

The criteria for establishing entitlement to reimbursement or payment of that part of private medical expenses incurred at MCHS for which the Veteran remains liable, other than any deductible, copayment, or similar payment owed under his third-party medical coverage, are met.  38 U.S.C. § 1725 (2012); 38 C.F.R. §§ 17.1002, 17.1005 (2017); Staab v. McDonald, 28 Vet. App. 50 (2016).

REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran served on active duty from April 1975 to April 1979.   

This appeal to the Board of Veterans’ Appeals (Board) is from a June 2015 decision by the Department of Veterans Affairs (VA) Health System in North Florida/South Georgia.  

Entitlement to reimbursement or payment for medical expenses incurred due to non-VA medical care at MCHS 

The Veteran contends that reimbursement or payment of that portion of unauthorized medical expenses that he incurred at MCHS in May 2015 is warranted. The record reflects that from May 21, 2015, through May 22, 2015, the Veteran received treatments for symptoms related to “insect/bug bite,” for which he is not service-connected.  See 38 U.S.C. § 1725 (2012). 

The Agency of Original Jurisdiction (AOJ) denied the present claim based on the Veteran’s third-party medical coverage, which the AOJ found to be a bar from reimbursement or payment from VA based on applicable statutes and regulations at that time.  See July 2015 Statement of the Case.  There is no dispute that the Veteran has satisfied the remaining conditions that allow for reimbursement or payment of his unauthorized medical expenses under 38 U.S.C. § 1725.

Since the AOJ’s determination, in April 2016, the United States Court of Appeals for Veterans Claims (Court) invalidated and set aside 38 C.F.R. § 17.1002(f) to the extent that the regulation acts as a bar to reimbursement in cases where a Veteran has only partial coverage under a health plan.  See Staab v. McDonald, 28 Vet. App. 50 (2016).  Accordingly, in cases where a Veteran seeks reimbursement or payment and had partial coverage, such as private insurance for the medical care at issue, VA reimbursement or payment is not precluded as a matter of law.  See id. 

Given the foregoing, entitlement to reimbursement or payment for that part of medical expenses incurred at MCHS from May 21, 2015, through May 22, 2015, for which the Veteran remains liable under his third-party medical coverage, other than any deductible, copayment, or similar payment, see 38 C.F.R. § 17.1005(f), is warranted.  38 U.S.C. § 1725; 38 C.F.R. § 17.1002; Staab, supra.  His appeal is granted to this extent. 

 

MARJORIE A. AUER

Veterans Law Judge

Board of Veterans’ Appeals

ATTORNEY FOR THE BOARD	S. Kim, Associate Counsel