Veterans who use the VA system for their healthcare are able to get the care they need without expenditures. But if the VA’s emergency care facility isn’t close enough, a trip to a local emergency room may be required.

A visit to an emergency room is just that—an emergency, usually a life-threatening one. Sometimes emergencies occur when a veteran isn’t able to make it to a VA facility. When time is of the essence, it’s important to find the closest available ER, whether or not it’s the VA’s.

Does The VA Cover Other Medical Expenses?

Veterans are told that if they need emergency care from outside the VA, they will be covered. But as veterans and their families have discovered, emergency care from a non-VA facility is quickly followed by bills. If a veteran has other health insurance, such as through their job, that may cover most of the expenses, outside of a deductible. But in many cases, private health insurance doesn’t cover absolutely everything, meaning that the policyholder must pay the balance out of his or her own pocket.

A veteran can file a claim with the VA to reimburse them for the balance, so long as that sum is no deductibles, co-payments, and co-insurance charges. Unfortunately, many veterans have seen their claims denied on that basis, even though that wasn’t the case.

The Deciding Court Case

In September of 2016, Coast Guard veteran Amanda Wolfe went to a local emergency room seeking treatment for an appendix that was ready to burst. Driving to the VA facility would be three hours and not enough time to be treated quickly as needed. With both her VA benefits and self-paid private insurance, Wolfe presumed that she would be covered.

Her expenses for the emergency visit totaled $22,348.25, and her private insurance covered all but $2,558.54. She filed a claim with the VA for the remainder, only to see the claim denied six months later. The reason, the VA said, was that amount fell under their exclusion for deductibles, co-payments, and co-insurance charges. This put Wolfe in financial hardship, and she personally paid off the amount in 2017.

Wolfe vs. Wilkie

In a case filed by Ms. Wolfe, the U.S. Court of Appeals for Veterans Claims (CAVC) found that the VA’s denial from a 2018 reimbursement regulation violates the Emergency Care Fairness Act of 2010 (ECFA). This regulation requires the VA to reimburse veterans for emergency care from a non-VA facility. The case was later certified as a class-action lawsuit on behalf of other veterans who were also denied reimbursements. The CAVC then ordered the VA to begin reimbursing veterans who saw their claims incorrectly denied.

The CAVC found that VA’s 2018 reimbursement regulation violates the Emergency Care Fairness Act of 2010 (ECFA) that requires VA to reimburse veterans for the emergency medical expenses they incur at non-VA facilities that are not covered by the veteran’s private insurance.

On April 6, 2020, the CAVC ordered the VA to begin mailing out “corrective notices” to more than 1 million veterans who were incorrectly notified that their expenses were not reimbursable by the VA. In the Wolfe case, the VA admitted that original notices with misinformation likely discouraged many veterans from submitting claims for reimbursements. The VA began sending out the corrective notices on April 13, 2020, and begin reviewing and re-deciding more than 72,000 denials beginning May 20, 2020.

Five years prior, in Staab v. Shulkin, the organization appealed to the CAVC after another veteran was denied $48,000 in reimbursements after open-heart surgery because he also had Medicare, which partly covered his bills. The CAVC found similar results in that case, and the VA violated the ECFA in its decision.

What This Means For Veterans Now

The VA’s website has a brief fact sheet on “community-based healthcare” for veterans available on its website.

For those who found their out-of-pocket expenses denied after an emergency room visit, it may be time to revisit the claim. You can call the VA to request information on your claim at 1-877-466-7124.

The VA’s Office Of Inspector General found that similar claim denials could add up to as much as $6.5 billion in repayments to veterans who were previously denied. The internal audit from the VA’s Inspector General is available online here.

Get Help From A Houston VA Disability Attorney

If you’ve been denied reimbursement for out-of-pocket expenses by the VA. You do have the right to legal representation when you come face-to-face with the VA’s bureaucracy.

Call The Herren Law Firm in Houston at 713-682-8194 (or use our online contact form) to schedule your free consultation for VA disability and other benefits. Our contingency fee basis means you won’t owe a fee until we win your case, and there’s no obligation.