Citation Nr: A21019763 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 190925-33085 DATE: December 13, 2021 ORDER Entitlement to payment or reimbursement for unauthorized medical expenses incurred at Hackley Hospital on July 9, 2017, and July 10, 2017, is denied. FINDINGS OF FACT 1. On October 23, 2017, the Veteran submitted a claim for payment or reimbursement for medical expenses incurred at Hackley Hospital on July 9, 2017, and July 10, 2017. 2. The condition for which the Veteran received treatment was not service-connected or caused or aggravated by his service-connected posttraumatic stress disorder (PTSD). CONCLUSION OF LAW The criteria for payment or reimbursement for unauthorized medical expenses incurred at Baptist Medical Center on October 26, 2013, are not met. 38 U.S.C. §§ 1725, 1728, 5107; 38 C.F.R. § 17.1004(d). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the United States Marine Corps from June 1975 to June 1979. In the September 2019 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. The Veteran seeks entitlement to payment or reimbursement for unauthorized medical expenses incurred at Hackley Hospital on July 9, 2017, and July 10, 2017. Private treatment records show that on July 9, 2017, the Veteran presented to an urgent care with dizziness and unsteady gait, and that emergency medical services subsequently took the Veteran to Hackley Hospital. Hospital records show that the Veteran suffered a stroke. See Private records (July 10, 2017). On October 23, 2017, the Veteran submitted a claim for payment or reimbursement for medical expenses incurred at Hackley Hospital on July 9, 2017, and July 10, 2017. In decisions issued in February and April 2018, the AOJ denied payment or reimbursement under 38 U.S.C. § 1728, on the basis that his October 23, 2017, claim was received more than 90-days after his July 10, 2017, episode of care. By way of a May 2019 letter, the AOJ notified the Veteran that the prior decisions contained notice letters that incorrectly described the legal criteria for entitlement to reimbursement under 38 U.S.C. § 1725. Specifically, the letter explained that other health insurance does not preclude reimbursement or payment; however, VA will not reimburse or pay private medical expenses to the extent that such were covered by other health insurance. The letter also states that the Veteran's claim was properly rejected under 38 U.S.C. § 1725 because VA records indicate that the Veteran has other health insurance and the evidence of record does not indicate which portion, if any, such other health insurance has covered. VA law provides to payment or reimbursement of unauthorized medical expenses incurred at a non-VA facility under 38 U.S.C. § 1728 and 38 U.S.C. § 1725. Initially, the Board finds that payment or reimbursement is not warranted under section 1728 as this statute requires that the disability be service-connected or caused or aggravated by a service-connected disability. Here, PTSD is the Veteran's sole service-connected disability. At the time of the treatment in question, the Veteran's PTSD was rated 70 percent disabling. Critically, none of the lay or medical evidence of record suggests that the stroke for which the Veteran received treatment was service-connected or caused or aggravated by his service-connected PTSD. Accordingly, payment or reimbursement is not warranted under section 1728. The Board also finds that payment or reimbursement is not warranted under section 1725 as the Veteran's October 23, 2017, claim was received more than 90 days after his July 10, 2017, treatment. See 38 C.F.R. § 17.1004(d)(1). To obtain payment or reimbursement under section 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). Here, the Veteran's claim lists "Veterans Administration" as his insurance plan name, but VHA records indicate that the Veteran had VISA/FBCS as insurance and that third party liability was not applicable. As the evidence of record shows that the Veteran is alive and that there is no indication of third party liability, the provisions of 38 C.F.R. § 17.1004 (d) (2-3) are not applicable in this case. As a result, per 38 C.F.R. § 17.1004(d)(1) the Veteran's claim for payment or reimbursement must have been received within 90 days of his July 10, 2017, treatment to warrant consideration under 38 U.S.C. § 1725. As his October 23, 2017, claim was received more than 90 days after his July 10, 2017, treatment, payment or reimbursement under 38 U.S.C. § 1725 is not warranted. For these reasons, entitlement to payment or reimbursement for unauthorized medical expenses incurred at Hackley Hospital on July 9, 2017, and July 10, 2017, is denied. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Joshua R. Castillo, 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.