Citation Nr: 19166148 Decision Date: 08/27/19 Archive Date: 08/27/19 DOCKET NO. 18-47 301 DATE: August 27, 2019 ORDER Entitlement to payment or reimbursement of unauthorized medical expenses for services provided by Surendra K. Sethi, MD, at Butler Memorial Hospital (BMH), in Butler, Pennsylvania, on May 4, 2017 and May 5, 2017, is denied. FINDING OF FACT The claim for payment or reimbursement of medical expenses was received more than 90 days after the Veteran’s discharge from the private facility. CONCLUSION OF LAW The criteria for payment or reimbursement for unauthorized medical expenses incurred on May 4, 2017 and May 5, 2017, at BMH, are not met. 38 U.S.C. §§ 1703, 1725, 5107; 38 C.F.R. § 17.1004. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Marine Corps from August 1972 to November 1972. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from November 2017 and July 2018 administrative determinations made by the Department of Veterans Affairs Medical Center (VAMC) in Butler, Pennsylvania. The appellant in this case is Sandra L. Cox, Business Representative for Butler Health System. This appeal was filed by Butler Health System on behalf of BMH and Surendra K. Sethi, M.D., the doctor who rendered medical care to the Veteran when he was hospitalized at BMH on May 4, 2017 and May 5, 2017. This appeal was processed after reviewing a paper-based claims file and relevant electronic records maintained in the Veterans Benefits Management System (VBMS) and Virtual VA (VVA) databases. Medical Reimbursement Claim The Board notes that the facts of this case are not in dispute. The Veteran was admitted to BMH on May 4, 2017, with complaints of severe chest pain over the last 2-3 days with minimal activity and even at rest, with the pain going down to the arm. Medical services were rendered by attending physician, Surendra K. Sethi, M.D. After examining the Veteran, Dr. Sethi ordered chest x-rays. The x-rays were unremarkable. Dr. Sethi diagnosed the Veteran as having acute coronary syndrome and elevated troponin levels with a history of coronary artery bypass surgery in 2009. Dr. Sethi recommended repeat cardiac catheterization with the possibility of coronary angioplasty and stent. The Veteran was discharged home on May 5, 2017. Thereafter, Butler Health System submitted claims for payment or reimbursement of medical expenses incurred for services rendered to the Veteran on May 4, 2017 and May 5, 2017. See Claims 3128343 ($340.00) and 3128346 ($4,890.00). Both claims were submitted to and accepted by VA on October 25, 2017. To obtain payment or reimbursement under 38 U.S.C. § 1725, a claimant must submit to the VA medical facility of jurisdiction a completed standard billing form (such as a UB92 or a HCFA 1500). See 38 C.F.R. § 17.1004(b). Also, to receive payment or reimbursement, a claimant must file a claim within 90 days after the latest of the following: (1) the date that the veteran was discharged from the facility that furnished the emergency treatment; (2) the date of death, but only if the death occurred during transportation to a facility for emergency treatment or if the death occurred during the stay in the facility that included the provision of the emergency treatment; or, (3) the date the veteran finally exhausted without success, action to obtain payment or reimbursement for the treatment from a third party. See 38 C.F.R. § 17.1004(d). Regardless, VA will provide retroactive payment or reimbursement for emergency treatment received by the Veteran on or after July 19, 2001, but more than 90 days before May 21, 2012, if the claimant files a claim for reimbursement no later than 1 year after May 21, 2012. See 38 C.F.R. § 17.1004(f). VA did not receive any claim for payment or reimbursement or billing documents, including a UB92 or HCFA 1500 from Butler Health System (or any associated billing representatives, vendors, or healthcare providers) until October 25, 2017, which is more than 90 days after the Veteran’s discharge from BMH on May 5, 2017; this is not disputed by the appellant in this case. Consequently, the claim must be denied at this time because Butler Health System did not file a timely claim for payment or reimbursement in this case. See 38 C.F.R. § 17.1004(d). The Board cannot grant the appellant’s claim without proper statutory and regulatory authority. The Board notes that VA is subject to Title 38 of the United States Code and the Code of Federal Regulations. The binding authority in this case are the laws authorized by the Congress of the United States and the Federal Government’s codified regulations. The correct binding authority regarding timeliness for filing claims for payment or reimbursement for unauthorized medical expenses with VA is cited above. The law in this case is clear that Butler Health System (and any associated billing representatives, vendors, or healthcare providers) had to file a claim for payment or reimbursement with VA within 90 days of the Veteran’s discharge from the BMH facility. The appellant’s delay in filing the claim does not provide a basis to waive this requirement. The Board recognizes the appellant’s contentions that there was an issue with the hospital bill and that the appellant waited for the hospital charges to be paid before he sought payment or reimbursement from VA for medical services rendered. It also appears that a payment was made to BMH on March 13, 2018. See July 2018 notice of disagreement; July 2018 printout showing a payment was made to BMH on March 13, 2018; and September 2018 VA Form 9. However, the fact remains that VA did not receive claims from the appellant until October 25, 2017. In that regard, the Board is bound by VA regulations regarding limitations on reimbursement, including time limitations for filing claims. See 38 U.S.C. § 1725(c)(1)(B); 38 C.F.R. § 17.1004(d). Similarly, there is no provision for benefits based on equity or fairness. The Board is without authority to grant the appeal on an equitable basis and instead is constrained to follow the specific provisions of the law. In summary, the record reflects, and the appellant does not dispute, that Butler Health System, did not meet the basic filing requirements (including the time limitations) for submitting a claim for reimbursement or payment of medical expenses. As the claim was not timely filed, the request for payment or reimbursement of unauthorized medical expenses incurred by the Veteran on May 4, 2017 and May 5, 2017, at BMH, in Butler, Pennsylvania, must be denied. See 38 U.S.C. § 1725; 38 C.F.R. § 17.1004. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. L. Marcum, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.