Citation Nr: 21000284 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 16-19 120 DATE: January 5, 2021 ORDER Entitlement to payment or reimbursement for the cost of medical treatment received at CHI Health St. Francis on May 30, 2015 is granted, subject to the laws and regulations governing the payment of VA monetary benefits. FINDING OF FACT The treatment received at the CHI Health St. Francis emergency room on May 30, 2015 was for a condition for which a prudent layperson would have believed that immediate medical attention was necessary to avoid hazard to health, and a VA facility was not feasibility available to provide the treatment. CONCLUSION OF LAW The criteria for payment or reimbursement for the cost of medical treatment received at CHI Health St. Francis on May 30, 2015 have been met. 38 U.S.C. § 1725; 38 C.F.R. § 17.1002. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from March 2004 to October 2005. The Veteran and his father testified before the undersigned Veterans Law Judge at a videoconference hearing in May 2019. A transcript is of record. Entitlement to payment or reimbursement for the cost of medical services received at CHI Health St. Francis on May 30, 2015 Initially, under 38 U.S.C. § 1703, when VA facilities or other government facilities are not capable of furnishing economical hospital care or medical services because of geographic inaccessibility or are not capable of furnishing care or services required, VA may authorize or contract with non-VA facilities for care. 38 U.S.C. § 1703(a); 38 C.F.R. § 17.52(a). However, the Veteran has never contended, and the evidence does not demonstrate, that he received prior VA written authorization for his private treatment on May 30, 2015. Therefore, application of 38 U.S.C. § 1703(a) for reimbursement of authorized private treatment is unwarranted. The issue of prior authorization is thus not applicable. Service connection was in effect for bipolar disorder at the time of the May 2015 treatment at CHI Health St. Francis with a rating of 100 percent. However, this treatment was not for a service-connected disability or for a disability that was aggravating a service-connected disability. Likewise, the treatment was not for any injury or an illness incurred in relation to participation in a vocational rehabilitation program. Consequently, the Veteran is not eligible for payment or reimbursement for the claimed emergency treatment under 38 U.S.C. § 1728. See 38 C.F.R. § 17.120. Payment or reimbursement for private emergency medical treatment may be considered under 38 U.S.C. § 1725. The primary requirements for payment or reimbursement under this statute are that the Veteran is treated in an emergency department or similar facility held out as providing emergency treatment to the public; the treatment received is 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 a VA or other federal facility was not feasibly available to provide the treatment. 38 C.F.R. § 17.1002(a-c). A condition that a prudent layperson would reasonably expect that delay in seeking medical attention would be hazardous to life or health can include one manifested by severe pain that results in serious dysfunction of a body part. 38 C.F.R. § 17.1002(b). The Veteran’s VA treatment records show that on May 30, 2015 there was a telephone encounter during which the Veteran reported that he had been vomiting for six weeks and that it had gotten worse over the past four days. The VA physician recommended that the Veteran be seen in an emergency department. The Veteran agreed and said that he would go to his local hospital’s emergency department because it would take three and a half hours to get to the VA emergency department in Omaha. At June 1, 2015 VA treatment the Veteran presented to follow up on the May 30, 2015 emergency treatment for acute abdominal pain. He said that the pain had begun four days before after he drank half a gallon of whiskey. The Veteran felt he had been “working on” a stomach ulcer for four months due to left upper quadrant pain. It was noted that the emergency room records showed a mildly elevated white blood cell count, and that otherwise the laboratory results were negative. A CT scan of the abdomen showed mild fatty liver disease. The Veteran reported that he only drank alcohol a couple times a month. The Veteran testified at the May 2019 hearing that he had been having chest pains on May 30, 2015. His father said that the Veteran passed out while helping to work on a tree. The Veteran also testified that he called VA three days prior going to the private emergency room on May 30 and was told to take aspirin and keep an eye on himself. The Veteran meets the requirement of 38 C.F.R. § 17.1002(a) that the May 30, 2015 treatment be provided in a hospital emergency department. The Veteran is also financially liable for the treatment. See 38 C.F.R. § 17.1002(e). Regarding the potential feasible availability of a VA or other federal facility, the VA emergency room in Omaha is approximately 180 miles from where the Veteran lives. CHI Health St. Francis is approximately 30 miles away. Given that the Veteran was advised by a VA physician over the phone on May 30, 2015 to go to a local emergency room because of the distance to Omaha, an attempt to wait to be treated until he could get to the VA emergency room would not have been considered prudent by a layperson. See 38 C.F.R. § 17.1002(c). In addition, a prudent layperson who possessed an average knowledge of general health and medicine would reasonably have expected that the absence of immediate treatment for the worsening pain would have placed the health of the Veteran in serious jeopardy or caused serious impairment to bodily functions. See 38 C.F.R. § 17.1002(b). Finally, there is no indication that the Veteran does not meet the additional criteria for reimbursement for emergency treatment under 38 U.S.C. § 1725, nor has the VAMC made any such finding. See 38 C.F.R. § 17.1002(d), (f)-(h). VA treatment records show that the Veteran was enrolled in the VA health care system and had been treated within the 24 months prior to May 30, 2015. See 38 C.F.R. § 17.1002(d). In addition, the Veteran did not have other health insurance that would fully pay for the May 30, 2015 treatment, the condition was not caused by a workplace accident, and coverage is not available under 38 U.S.C. § 1728. See 17.1002(f)-(h). The Veteran’s appeal is therefore granted, subject to the provisions governing the amount of payment or reimbursement that is available under 38 U.S.C. § 1725. 38 C.F.R. § 17.1005. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Scott Shoreman, 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.