I have searched the site (and elsewhere!) and read what has been posted about VA Fact Sheet 16-7. I served many years ago and am newly service connected (90%) and newly enrolled in VA healthcare, having never before had personal experience with the VA except for securing original GI Bill education benefits. I believe I generally understand about fee basis services (if not pre-approved, then must be for emergency, no VA facility available, etc.) for vets who are in the situation I am in NOW--that is, after having been found to have service connected conditions and being currently enrolled in and receiving regular treatment from the VA healthcare system.
My question concerns the medical care and services I received and paid significant deductibles and co-pays for under private insurance prior to award and enrollment. From the time I filed for service connection (later awarded) and the date of the award, I spent out of pocket about $6,000 for care of the conditions later determined to be service connected. I was lucky to have had good insurance coverage. At no time while these expenses were incurred would I have qualified for any priority group for enrollment with VA healthcare.
Fact Sheet 16-7 addresses this situation, but it does so in a very confusing way, at least it seems to me. In stating that the VA "in limited circumstances, may provide reimbursement of non-VA medical expenses for veterans for their service-connected conditions to include those who are recently granted service-connected awards", it is getting to my situation of non-VA medical expenses where the service-connected award is recent. However, the fact sheet then recites the general qualifying criteria that apply to the fee based services that the VA will cover for vets who are already service connected. Then, the example used is a retroactive award example, which is exactly my situation again.
Here's my question:
Where (1) the vet is receiving treatment for a condition(s) from private physicians, hospitals, etc. (2) during the period that a VA claim is pending for those conditions (3) the vet has no condition which has been determined by VA to be service connected at the time (4) the vet is not enrolled in VA healthcare and does not qualify for enrollment under any of the priority groups prior to the award and (5) the condition(s) is found to be service-connected in the award with the vet eligible for Priority Group 1, can the vet qualify for reimbursement of out of pocket expenses of treatment during the retroactive award period?
Believing that reimbursement is available, I have submitted the documentation to the fee basis office at my VAMC immediately adjacent to the private hospital where I was treated in the format suggested by Fact Sheet 16-7. They are absolutely flummoxed! It has been 7-1/2 months and they have made no progress. Please advise. If possible, provide authority.
Thanks in advance!
Fact Sheet 16-7June 2009Reimbursement of Non-VA Medical Expenses for Service-Connected VeteransBenefit DescriptionThe Department of Veterans Affairs (VA), in limited circumstances, may provide reimbursement of non-VA medical expenses for veterans for their service-connected conditions to include those who are recently granted service-connected awards.General Qualifying Criteria• A medical emergency• VA or other Federal facility not feasibly available• Care or service was for a service-connected disabilityTime Limit For Filing Claim Of Non-VA Medical Expenses:Generally within 2 years of the date of service or notification of the allowance of a service-connected award (which may include care/services back to the effective date of award in cases of retroactive award – see example).Retroactive Award ExampleA veteran is awarded service-connected status via a Veterans Benefits Administration award letter dated January 1, 2007. The veteran filed the initial claim for service-connection on May 1, 2006. The service-connected award is retroactive to May 1, 2006.The veteran may file a claim for private medical expenses care of the service-connected condition from May 1, 2006 forward as long as this claim is filed by January 1, 2009.Where to File ClaimsVeterans may file a claim for private medical expenses with their local VA health care facility’s Fee Basis office.For Further InformationContact your local VA health care facility’s Fee Basis office or VA at 1-877-222-VETS (8387). Authorities: Title 38, United States Code, §1728 and Title 38, Code of Federal Regulations, §17.120-132.
Some posts on this site have discussed how they applied for reimbursement of expenses incurred for service