Re-embursement for non VA Medical care.

[Hawks and Doves]

I was traveling in Australia and had to go the a local emergency room at a local hospital for treatment. This is illness is unrelated to any already compensated for service related disability. I am not trying to get my disability increased. All I want to do is to be re-embursed for the bills caused by this emergency room visit.  I sent the appropriate form and attached documentation, (VA Form 10-583 Claim For Payment of Costs Unauthorised Medical Services), to my local VA Medical Center. When I followed up in person they could not find any information related to my inquiry. I could not seem to be able to get it across is that I do not want increased compensation, just re-embursement for an emergency room visit. I was directed to re-sent (VA Form 10-583 Claim For Payment of Costs Unauthorised Medical Services), and all documentation to  this address, Department Of Veterans Affairs Evidence Intake Center, P.O. Box 4444, Janesville, WI 53547-4444, which I did.

I got a letter back saying the the information that I received was placed in VA records and that I submit a, (VA Form 21-526EZ, Application for Disability Compensation and related Compensation Benefits). Once again it seems I was misunderstood, I not want increased compensation, just re-embursement for an emergency room visit Any assistance in this matter is appreciated.

Thanks

 

 

 

 

[broncovet]

Welcome to hadit!  

    There are certain rules about community care reimbursement, and I have no idea if you met them or not.  Try reading this:

https://www.va.gov/resources/getting-emergency-care-at-non-va-facilities/

   However, (and I have no idea of knowing whether or not you would likely succeed) Im unsure of why you seem to be so adamant against getting an increase in disability compensation.  

   When I buy stuff, say at Kroger, or pay bills, I have never had anyone say, "Wait!  Is this money from disability compensation, or did you earn it working at a regular job?"  Not once.  Thus, if you did get an increase, likely you would have no trouble paying this with the increase compensation.  

    However, there are many false rumors out there that suggest if you apply for an increase, the VA will reduce your benefits instead.  

That rumor is false but I do hear people tell Veterans that a lot.  There are strict rules VA has to reduce you and, NOT ONE of those rules have anything to do with applying for an increase.  

Yes, the VA can reduce your benefits, but generally only when your condition has "actually improved" under ordinary conditions of life.  

    Unless you contacted the VA within 72 hours of your medical treatment, you may not be eligible for reimbursement, or at least that is how I read the link, I posted above. Here are SOME of the rules the VA must comply with in order to reduce your compensation benefits:

https://www.law.cornell.edu/cfr/text/38/3.344

 

Edited Thursday at 01:49 AM by broncovet

[Hawks and Doves]

Thanks for your quick response. The link you sent gave me a quick answer to my question. I did not make the 72 hour requirement, oh well lessons learned. But I now know of the online portal for non-VA emergency care. I added a link on my browser to make it easy to find the portal if there is a need in the future.  

I just wanted that $640 USD that I payed out back.

Yes, maybe I am a bit paranoid about stirring the increased disability pot. In the past I did apply for additional disability and my 80% was reduced to 70%. It took me two years do put get it back. In my case the VA admitted they made an error and I was given retro pay for the entire period of the reduction. Additionally they decided that I was totally disabled for VA purposes and now pay me at the 100% rate due to unemployability. 

Again Thanks

Hawks&Doves

CPO/USN/Retired

 

 

[broncovet]

Im happy to help.  You may well be "leaving money on the table" by NOT applying for additional benefits to which you are entitled.   Did you know you can get "above" 100 percent from VA?  Its a myth that once you get to 100 percent, you can get no more, and VA loves to perpetuate this myth.  

In addition to 100 percent ratings many Veterans, including myself, get SMC (Special Monthly Compensation).  There are many SMC's.  Often, Veterans begin SMC with things like SMC S, often called housebound.  

There are 2 ways to qualify for SMC S, which will currently amount to about an additional $450 per month:

1.  If you have a single 100 percent rating "and one or more additional ratings which combine to 60 percent or more, that are seperate and distinct, you qualify for SMC S.  TDIU "counts" as a single 100 percent rating, so that would mean you would need an additional 60 percent (one or more ratings) to get Statuatory SMC S.  You do not have to prove you are housebound with this method.  It is supposed to automatically be awarded, when you reach the critera, BUT VA often "misses" it and neglects to pay you for this, so you need to apply.    In order for you to qualify for this, it may involve you applying for additional disabilites, or an increase, and being awarded the same if you dont already meet the criteria.  

2.  Housebound "in fact".  This generally means you have to have a c and p exam where your doctor can decide if he thinks you are "substantially confined" to your home.  This does not mean you can never leave your home, it means you mostly stay at home.  

    Other popular SMC's, which would provide additional income to you are:

SMC L.  Aid and Attendance.  You can get SMC L "even if/when" your spouse or family member provides help to you.  A and A generally means you need assistance with ADL (Activities of Daily Living), such as eating, getting dressed, bathing, etc.  Generally, to get A and A, you often need a c and p exam.  The form to apply for A and A, is on the same form as housebound, described above.  You can get A and A OR housebound, but not both.  A and A is the larger of the two, so if you get help from others, then go for that.  Often VA will do an exam and award the lower (housebound), but that depends on what your doctor so states.  There are even different levels of A and A, for example, if a nurse has to come to your home to do IV's, change bandages, etc, or do stuff that nurses are qualifed to do, but your family probably is not qualifed to do.  Since my wife is a retried nurse, theoretically I could get the higher level of A and A, if, indeed, I needed nursing care.  Getting a nurse to come to your home is often way, way cheaper (and often better) than care in a nursing home, and VA knows this.  

SMC K. SMC K is for Loss of use.  A common way Vets get awarded SMC K is if they have erectile dysfunction, due to a service related condition.    Many medications, for example, are known to cause ED, especially those for Veterans with one or more mental health ratings, such as PTSD.  You can get awarded "more than one" SMC K rating.  

Other SMC ratings are also for loss of use:  Your legs, your eyes, your arms/hands, your bowels, such as if you can not control them, are just a few examples.  Some Veterans have amputations, and those should make the Veteran eligible for additional SMC, BUT often you wont get it unless you apply.  

The great part of SMC:  If you apply for SMC tommorrow, for example, and your doctor, upon a c and p exam, notes that your wife has been providing necessary assistance for you since June 1, 2008, then you could get retro active pay back to 2008 even thos you did not apply until 2024.    In this example, you could get a retro active check of more than $50,000 from VA.  How do I know this?  Because I was awarded SMC housebound, which was paid back to 2006, when I first met the applicable criteria.  

[Hawks and Doves]

Thanks for your response. At this point in time do not meet any day of conditions that you mentioned. But I am aware that theirs is more an available if my condition changes. When you add up E-7 over 20, VA disability at 100%,  and Social Security I am making more retired than I ever did working.  More seems greedy. That may change in the future. Only time will tell. Again thanks. 

[Lemuel]

Thanks bronco.  I qualify for SMC-S from mid 2009 I think.  TDIU 100% from 09/1985, TBI 40%, 2009, Mixed organic personality syndrome 30%,  Hearing deficit 20%, 1984, Tinnitus 10% 1989 for combined 70% from 7/10/2009.

Is my assessment correct and will CCK be able to get the back payment for SMC-S until my SMC-T starts?

Edited Thursday at 09:53 PM by Lemuel

[broncovet]

Lemuel

   Short answer:  IDK

    But your assessment is almost certainly better than mine because you know your health history 10 times better than I do,  I have not read your file and IDK if your conditions are "seperate and distinct" as required by the regulations for SMC S (statuatory).  

   Even better, for you,  is that if cck represents you, THEY are betting their own money that they can get you retro.   CCK law is not a "non profit" organization, and they have to earn enough to stay in business unless the owners won the lottery and are doing this because they are bored.   You see, to represent you, they have costs:  They have to pay the people who work on your claim, they do not work for free.   And, they have invested considerable time, and money to get you to where you are.  When you go into a restaurant, they serve you a meal and expect you to pay at the end.  Sure, they do have people who steal meals from them, but most of the time, they get paid.  In a similar way, CCK law would unlikely "serve" you (a meal of legal services) unless they expected full payment.  CCK law does not win 100 percent of the time similar to  most of the rest of us, but they win enough.   People who have a job dont get paid except for one day per month, or week, as applicable, but most of them go into work and work diligently the other 4 days, not just on payday.  They probably are not even disappointed they dont get paid each and every day, but are happy to pick up their check or electronic deposit on Friday.  

    In a similar way, CCK law understands they wont win each and every one, but the do hand pick who they want to represent, and they pick ones they feel confident they can win.  

   Based solely on what you posted already, I will go out on a limb and say you have an 80percent probablility, or better, of at least getting SOME retro.  The most likely would be you get retro back to when you first met the criteria, and, if you are awarded SMC T, you should also get retro on that back to when you meet that criteria.  I can not opine if you will get your back pay on smc s before you get SMC T, it is 100 percent a guess without reviewing your file.