VETERAN DENIED MEDICAL/DENTAL BENEFITS

Dateline: September 18, 2012

I applied to the Veteran’s Administration for medical/dental benefits. On September 19, 2012 I received the “denial letter” from the VA Loma Linda Healthcare System, wherein it describes the reasons for the denial.

Rather than editorialize on the letter, I’ll reprint here that letter in its entirety. Please note that the Veterans Administration did not “directly” reply to my application. However, in our Morongo Basin region, the Palm Desert VA Clinic is where our local VETs go for treatment, and, the Loma Linda Hospital is the contracted acute care center for VETs who need such intensive care.

The letter follows:

VA Loma Linda Healthcare System
11201 Benton Street – Loma Linda CA 92357
800-741-8387  -  909-825-7084
www.lomalinda.va.gov

Sept 18, 2012

Dear Mr. Ford,

In 1996, Congress passed legislation, making veterans eligible for a medical benefits package that includes inpatient and outpatient care and pharmacy benefits. Most veterans must enroll in order to be eligible for care. Enrollees are classified in an enrollment “priority group” with Priority Group 1 having the highest priority and Priority Group 8 having the lowest priority. Each year, the Secretary is required to determine the number of veterans to whom [the] VA can provide timely, quality care. The Secretary is required to restrict enrollment when resources [funds] are not sufficient to provide all enrollees quality health care.

On January 17, 2003, the Secretary made the difficult decision to suspend new enrolments of veterans who are assigned Priority Group 8. This suspension will allow [the] VA to protect the quality of care and reduce waiting times for other enrollees, including those who were disabled by their military service, have lower incomes or who have special medical needs.

Who is affected by this decision?
Veterans who apply for enrollment on or after January 17, 2003, and are assigned to Priority Group 8 will not be accepted for enrollment. Previously enrolled Priority Group 8 veterans can continue to receive [medical] care. VA will continue to enroll veterans assigned to Priority Groups 1 through 7.

<according to our records [Mr. Ford], you are not eligible for enrollment at this time since you applied for enrollment on or after January 17, 2003 {but of course, this is 2012}, and are assigned to Priority Group 8.>

Which Veterans are in Priority Group 8?
Veterans in Priority Group 8″g” (see page 2):

  • do not have a compensable service-connected disability or other eligibility status that qualifies them for placement in a higher priority group, and
  • have annual incomes above both VA’s national “means test” threshold and the “low-income” threshold for public housing set by the U.S. Department of Housing and Urban Development (HUD) for their locale. VA’s “means test” threshold for a single veteran is $26,902 and $32,285 for a veteran with just one dependent. Information about the HUD threshold is available at http://www.hud.gov/renting/phprog.cfm .

Why was this decision necessary?
VA has seen dramatic increases in the number of enrollees — from 3.8 million in 1996 to 6.8 million in 2002, Va treated 1.4 million more patients than in 1996 — with 20,000 fewer health care providers (employees). VA has been unable to provide all enrolled veterans timely access to quality health care because of the tremendous growth in health benefits enrollment. As of January 2003, approximately 236,000 veterans are on waiting lists to receive an “appointment”.

[page 2]
 

What Veterans should Know

  • Veterans are still eligible to receive care at no cost to them for:
  • Their service connected conditions
  • conditions related to military sexual trauma,
  • conditions relating to exposure to Agent Orange, ionizing radiation, or environmental contaminants, or
  • head or neck cancer related to nose or throat radium treatment while in the military.
  • Veterans with a permanent, severely disabling injury or condition that compromises their ability to carry out the activities of daily living and requires use of personal or mechanical assistance to leave home or bed or requires constant supervision to avoid physical harm, may be determined to be catastrophically disabled and placed in Priority Group 4.
  • Va will provide medical care on a humanitarian basis for veterans who cannot be enrolled but who require immediate treatment. Please note: the VA must charge usual and customary fees for such services/care.
  • Veterans who served in combat locations can receive health care for conditions potentially related to their service for two years following discharge/release from military service.
  • Contact a Health Benefits Advisor at 909-825-7084 [Southern Calif] at extensions 1401 or 1045 to see if you may qualify for these exceptions.

What Veterans can do if they disagree with this decision:
Follow the instruction on the enclosed VA Form 4107VHA, “Your rights to appeal our Decision.” The notice of disagreement should be delivered to the enrollment coordinator at your local VA health care facility. While the Enrollment Coordinator cannot reverse the Secretary’s decision about Priority 8s, the Coordinator will personally review your concerns and determine if you qualify for enrollment or care under any exceptions. If we cannot rule in your favor, you will be provided a Statement of the Case, which describes the facts, laws, regulations and reasons for our decision.

Sincerely,

{Name withheld}
Patient Services

[end of letter as received]

NOTE: While the ending dialogue suggests that the “appeal” form was enclosed with the letter, in fact, no such document was included with this response.

\\\

About Bill Ford, Founder

Born in the late 30s - you do the math. Lots of life experiences in numerous endevors but not an expert in any that I know of. I'm a fan of challenging projects. When I'm told it can't be done I go ahead and do it anyway. This web site is one of 'em. How long will this web site last? Hard to say. Depends on how long I live. Film at Eleven. --bf
This entry was posted in Local Government Issues, Local Senior Citizen Forum, Misc Topics and tagged , , , , , , . Bookmark the permalink.

4 Responses to VETERAN DENIED MEDICAL/DENTAL BENEFITS

  1. Doug Foster says:

    I had a very similar complaint about the enrollment cutoff date off January 17, 2003 . I was placed in priority group 8g even though I had been to Vietnam and was requesting a Agent Orange examination to find out if any of my current ailments were associated with the exposure to A.O.. I should have been in priority group 6 and would have gotten enrolled. I sent a copy of my DD214 with my request for an exam but it could have been misplaced when it was reviewed. I specifically asked for the A.O. exam on the form. I had no internet access at that time and didn’t have any place to stay informed about VA that I knew about. I assumed I was in the VA system for all benefits but was denied because I made more money than their threshold amount available at the time. I just accepted it and forgot about it at the time.
    Now I want to file an appeal to see if I can get accepted at that time. I had a Ischemic Heart Disease issue in early 2003 but thought I was enrolled in the claim system of the VA, so I didn’t reapply. What is your opinion of the result if I appeal the wrong priority group placement by the VA thus denying me the earned benefits that I should have gotten for the last 9 years. I have filed a claim now but would like my established date to be 2003 and not 2012. Thanks for your time,
    Doug

    • Mr. Foster:
      Thanks for your comment and details.

      Unfortunately, I am not very well versed on the workings of the VA. I had not “enrolled” in the VA medical/dental benefits program since discharge in the mid 1950s. Now, more than half a century later, I come down with cancer on the left lung and discover that I cannot “sign up” after 2003, not to mention that my “income” is greater than their threshold of $26,902. So, I simply “filed” the paperwork and VA response.

      In your situation, you “may” have a “case” for an appeal. I would suggest that you contact your “local” VA hospital (or clinic) and interview with a real person who may be able to help with sorting out whether you can file an appeal or not, and how to go about doing that.

      I also suggest you do the “interview” in person, not via Internet, email, or telephone or fax. Bring with you any historical documents you have pertaining to the AO issue (or other issue) and suggest that you “applied for benefits” in a timely manner but never received any confirming reply — causing you to believe you were “accepted” without fanfare.

      Let me know what happens……
      BF

      • Doug Foster says:

        I went to a VSO and told her about the situation. She said you will not get claim back dated to 2003 , it was my screw up by not appealing within a year deadline and not theirs by putting me in the wrong catagory in the beginning. I guess she knows what she is talking about but she said she would send my letter with the claim but I doubt that she did. She said I was just gonna get her laughted at for even sending it.

        • Hi Doug

          Sorry for the mix up you’ve experienced. I kinda thought “they” would suggest that since you “didn’t appeal” in a timely manner, that in itself would kill your request for redress.

          BF

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>