Citation Nr: 21074104 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-04 788A DATE: December 14, 2021 REMANDED Entitlement to payment or reimbursement of medical expenses incurred on October 31, 2015, at Temecula Valley Hospital (TVH) remanded. REASONS FOR REMAND The Veteran served on active duty from November 2005 to November 2009. This appeal is before the Board of Veterans' Appeals (Board) from a September 2016 decision of the Department of Veterans Affairs (VA) Veterans Health Administration. On October 31, 2015, the Veteran received treatment at the TVH emergency room for severe upper abdominal pain of one-hour duration with nausea and vomiting. She was evaluated and treated for symptomatic cholelithiasis. She seeks payment or reimbursement of the expenses of her emergency treatment. The Veterans Millennium Health Care and Benefits Act provides general authority for reimbursement for the reasonable value of emergency treatment furnished in a non-VA facility to those Veterans who are active VA health-care participants (i.e., enrolled in the annual patient enrollment system and recipients of a VA hospital, nursing home, or domiciliary care under such system within the last 24-month period) and who are personally liable for such non-VA treatment and not eligible for reimbursement under the provisions of 38 U.S.C. § 1728. 38 U.S.C. § 1725; 38 C.F.R. §§ 17.1000-1008. To receive payment or reimbursement for emergency services under 38 U.S.C. § 1725, a claimant must file a claim within 90 days after the latest of the following: the date that the veteran was discharged from the facility that furnished the emergency treatment; the date of death, if the death occurred during transportation to a facility for emergency treatment or during the stay in the facility that included the provision of the emergency treatment; or the date the veteran finally exhausted, without success, action to obtain payment or reimbursement for the treatment from a third party. 38 C.F.R. § 17.1004(d). If after reviewing a claim the decisionmaker determines that additional information is needed regarding the claim, such official will contact the claimant in writing and request additional information. The additional information must be submitted to the decisionmaker within 30 days of receipt of the request or the claim will be treated as abandoned, except that if the claimant within the 30-day period requests in writing additional time, the time-period for submission of the information may be extended as reasonably necessary for the requested information to be obtained. 38 C.F.R. § 17.1004(e). The date of filing any claim for payment or reimbursement of the expenses of medical care and services not previously authorized shall be the postmark date of a formal claim, or the date of any preceding telephone call, telegram, or other communication constituting an informal claim. 38 C.F.R. § 17.127. Entitlement to payment or reimbursement of medical expenses incurred on October 31, 2015, at TVH remanded. As reflected in its September 2016 decision and December 2016 statement of the case, the agency of original jurisdiction denied the Veteran's claim on the basis that it had not been timely filed pursuant to 38 C.F.R. § 17.1004(d). As reflected in her September 2016 notice of disagreement and January 2017 substantive appeal, the Veteran asserts that TVH billed the VA in San Diego within 90 days of her October 31, 2015, treatment several times, but that VA refused to pay the bill, first explaining that TVH had the incorrect Social Security number for the Veteran, and then that the denial was due to the Veteran's active status, and then that it was due to the fact that she was not registered with the VA hospital closest to her. She asserts that, by the time she registered at the hospital and resubmitted her claim, the time limit for filing the claim had expired, and her claim was denied as not being timely. In her Veteran's January 2017 substantive appeal, she stated that TVH was able to show proof of timely billing to VA and was going to fax a letter explaining what happened, and that the Veteran had been told by VA that this would be sufficient evidence for showing timely filing. It appears that, in this case, the claims file was previously a paper file, and has since been scanned and uploaded to an electronic file. It is not entirely clear whether the file is complete or whether portions might be missing. In this regard, despite the Veteran's assertions in her January 2017 substantive appeal regarding the evidence she had to substantiate her claim, no such evidence is of record, and there is no indication of any further correspondence regarding such evidence between her and VA. Given this, the Veteran should be given another opportunity to submit evidence of timely filing of her claim. Also, September to December 2016 VA administrative notes indicate that VA personnel spoke to the Veteran regarding her assertions of timely filing and attempted to verify the assertions with accounting and with the VA in San Diego but were unable to do so. As such, VA should again make attempts to verify, through its own records, the Veteran's assertion that she and TVH made multiple attempts file a medical reimbursement claim with VA within 90 days of her October 31, 2015, treatment at TVH, and formally document any such attempts. The matter is REMANDED for the following action: 1. Request that the Veteran submit evidence of timely filing of her claim for payment or reimbursement of medical expenses incurred on October 31, 2015, at TVH, to include any records of such from TVH. Make all reasonable attempts to assist the Veteran in obtaining any such evidence. 2. Make attempts to verify through VA records the Veteran's assertion that she and TVH made multiple attempts file a medical reimbursement claim with VA within 90 days of her October 31, 2015, treatment at TVH. This should include obtaining any records of communication between the Veteran and VA during this period. Any such attempts should be formally documented. 3. After completing the above and any other necessary development, readjudicate the appeal. If any benefit sought remains denied, provide a supplemental statement of the case to the Veteran. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mack, Andrew 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.