13-18 540
13-18 540
| Board of Vet. App. | May 31, 2017Background
- Veteran served active duty 1964–1968; sought reimbursement for non-VA medical care at Cassia Regional Medical Center on Jan. 4, 2012 for a nuclear cardiac stress test after recent myocardial infarction and stent placement.
- Veteran was enrolled in VA health care, had no other insurance, and was financially liable for the hospital charges ($7,226.06).
- On Jan. 3, 2012 the private physician attempted but failed to transfer the Veteran to a VA hospital; the Twin Falls CBOC authorized the non-VA physician to perform the test.
- The procedure required radiopharmaceuticals unavailable that day at Cassia, so it was scheduled for Jan. 4; the Veteran was discharged Jan. 3 and returned the next day for the test.
- VA reviewers denied reimbursement, reasoning the procedure occurred after discharge and that the Veteran could have been treated at a VA facility within 200 miles.
- The Board found competent medical and lay evidence (including VA and private physicians) that the test was urgent, that reasonable transfer attempts were made, and resolved doubts in the Veteran’s favor, granting reimbursement.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether emergency non‑VA care on Jan. 4, 2012 qualifies for reimbursement under 38 U.S.C. § 1725 | Veteran: Test was emergent; VA authorized it on Jan. 3; transfer attempts failed; facility couldn’t perform test immediately | VA: Procedure occurred after discharge; therefore not part of emergency care and could have been obtained at a VA facility | Granted: Board applied liberalized § 1725 standard, found prudent‑lay emergency, documented transfer attempts, and awarded reimbursement |
Key Cases Cited
- Barger v. Principi, 16 Vet. App. 132 (Board duties to notify/assist not governed by VCAA in Chapter 17 claims)
- Lueras v. Principi, 18 Vet. App. 435 (same principle regarding VCAA applicability)
- Swinney v. Shinseki, 23 Vet. App. 257 (use totality of circumstances and both medical and lay evidence in prudent‑lay evaluation)
- Zimick v. West, 11 Vet. App. 45 (all eligibility elements are conjunctive for § 1725 reimbursement)
- Malone v. Gober, 10 Vet. App. 539 (conjunctive nature of reimbursement criteria)
- Melson v. Derwinski, 1 Vet. App. 334 (statutory conjunctive interpretation)
- Johnson v. Brown, 7 Vet. App. 95 (contrast on conjunctive/disjunctive statutory reading)
- Gilbert v. Derwinski, 1 Vet. App. 49 (benefit of the doubt rule in veterans claims)