B-141235, DEC. 18, 1959

B-141235: Dec 18, 1959

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- SUBMITS THE FOLLOWING QUESTION FOR DECISION: "IS REIMBURSEMENT FOR DEPENDENT MEDICAL CARE REIMBURSABLE WHERE EMERGENCY HOSPITALIZATION WAS DUE TO A CONTINUING MENTAL DISORDER. SUPPORTING DOCUMENTS INDICATE THAT ARRANGEMENTS AT CIVILIAN HOSPITAL WERE MADE PRIOR TO HOSPITALIZATION? THAT IN 1957 THE NEUROPSYCHIATRY SERVICE AT WALTER REED HOSPITAL ADVISED HIM THAT FURTHER THERAPY WOULD HAVE TO COME FROM A CIVILIAN MEDICAL FACILITY. HOSPITALIZATION WAS TERMINATED ON AUGUST 29. WHICH PROVIDES THAT "HOSPITALIZATION AND MEDICAL CARE ARE AUTHORIZED AT GOVERNMENT EXPENSE FOR SUCH EMERGENCIES ONLY PENDING COMPLETION OF ARRANGEMENTS FOR CARE ELSEWHERE UNLESS THE ILLNESS OR CONDITION ALSO QUALIFIES FOR HOSPITALIZATION UNDER OTHER PROVISIONS OF THE LAW OR DIRECTIVE.'.

B-141235, DEC. 18, 1959

TO CAPTAIN R. E. CARIGNAN, DEPARTMENT OF THE ARMY:

YOUR REQUEST DATED AUGUST 18, 1959, FOR ADVANCE DECISION AS TO THE VALIDITY OF A CLAIM FOR REIMBURSEMENT OF EXPENSES INCURRED FOR DEPENDENT'S MEDICAL CARE SUBMITTED BY MASTER SERGEANT PHILIP R. SIDMORE -- FORWARDED BY THE CHIEF, FIELD DIVISION, OFFICE OF THE CHIEF OF FINANCE, INDIANAPOLIS, INDIANA, UNDER DATE OF NOVEMBER 12, 1959--- SUBMITS THE FOLLOWING QUESTION FOR DECISION:

"IS REIMBURSEMENT FOR DEPENDENT MEDICAL CARE REIMBURSABLE WHERE EMERGENCY HOSPITALIZATION WAS DUE TO A CONTINUING MENTAL DISORDER, AND SUPPORTING DOCUMENTS INDICATE THAT ARRANGEMENTS AT CIVILIAN HOSPITAL WERE MADE PRIOR TO HOSPITALIZATION?

THE CLAIMANT STATES THAT HIS WIFE'S MENTAL CONDITION HAS BEEN DISTURBED SINCE 1954; THAT IN 1957 THE NEUROPSYCHIATRY SERVICE AT WALTER REED HOSPITAL ADVISED HIM THAT FURTHER THERAPY WOULD HAVE TO COME FROM A CIVILIAN MEDICAL FACILITY; THAT HER DEPRESSIVE REACTIONS BEGAN AGAIN IN JULY 1958; AND THAT SHE ENTERED THE WASHINGTON SANITARIUM AND HOSPITAL ON AUGUST 5, 1958, FOR EMERGENCY TREATMENT. HOSPITALIZATION WAS TERMINATED ON AUGUST 29, 1958. YOU CITE AS AUTHORITY PARAGRAPH 4 OF ODMC LETTER NO. 2-/58), DATED JANUARY 2, 1958, WHICH PROVIDES THAT "HOSPITALIZATION AND MEDICAL CARE ARE AUTHORIZED AT GOVERNMENT EXPENSE FOR SUCH EMERGENCIES ONLY PENDING COMPLETION OF ARRANGEMENTS FOR CARE ELSEWHERE UNLESS THE ILLNESS OR CONDITION ALSO QUALIFIES FOR HOSPITALIZATION UNDER OTHER PROVISIONS OF THE LAW OR DIRECTIVE.'

YOU STATE THAT THE "MAJOR ARMY COMMANDER HAS PRIMARY AUTHORITY FOR REVIEWING AND PROCESSING CLAIMS OF THIS NATURE, UNDER INSTRUCTIONS FURNISHED BY THE EXECUTIVE AGENCY," BUT THAT NOTWITHSTANDING THE GENERAL OR SPECIAL INSTRUCTIONS RECEIVED, THE MAJOR ARMY COMMANDER "HAS DISALLOWED THE ORIGINAL CERTIFICATION" AND SUGGESTED THAT THE CLAIM BE FORWARDED TO THIS OFFICE. YOUR STATEMENT THAT "ARRANGEMENTS FOR CARE ELSEWHERE" WERE MADE PRIOR TO HOSPITALIZATION IS NOT UNDERSTOOD INASMUCH AS THE "CARE ELSEWHERE" MENTIONED IN PARAGRAPH 4 OF THE ODMC LETTER DATED JANUARY 2, 1958, WOULD APPEAR TO REFER, AS FAR AS THIS CASE IS CONCERNED, TO COMMITMENT TO A MUNICIPAL OR STATE MENTAL INSTITUTION. SEE PARAGRAPH 6.A. (1) OF THAT LETTER. ALSO, WHILE YOU STATE THAT THE MAJOR ARMY COMMANDER "HAS DISALLOWED THE ORIGINAL CERTIFICATION" AND SUGGESTED THAT THE CLAIM BE FORWARDED TO THE GENERAL ACCOUNTING OFFICE, IT IS NOTED THAT BY NINTH INDORSEMENT DATED AUGUST 11, 1959, THE MATTER APPEARS TO HAVE BEEN APPROVED FOR PAYMENT BY THAT OFFICIAL.

ARMY REGULATIONS 40-121, DATED NOVEMBER 5, 1956, PROVIDES, IN PERTINENT PART, AS FOLLOWS:

"14B. TREATMENT MAY BE PROVIDES (IN FACILITIES OF THE UNIFORMED SERVICES) FOR ACUTE EMERGENCIES OF ANY NATURE WHICH ARE A THREAT TO THE LIFE, HEALTH, AND WELL-BEING OF THE PATIENT INCLUDING ACUTE EMOTIONAL DISORDERS. HOSPITALIZATION IS AUTHORIZED AT GOVERNMENT EXPENSES FOR SUCH EMERGENCIES ONLY PENDING COMPLETION OF ARRANGEMENTS FOR CARE ELSEWHERE * *

"24. MEDICAL AND HOSPITAL CARE AUTHORIZED FROM CIVILIAN SOURCES. MEDICAL AND SURGICAL CARE FROM CIVILIAN SOURCES IS AUTHORIZED FOR SPOUSES AND CHILDREN FOR THE FOLLOWING:

"G. TREATMENT IN A HOSPITAL OF ACUTE EMERGENCIES OF ANY NATURE WHICH ARE A THREAT TO THE LIFE, HEALTH OR WELL-BEING OF THE PATIENT, INCLUDING ACUTE EMOTIONAL DISORDERS. HOSPITALIZATION IS AUTHORIZED AT GOVERNMENT EXPENSE FOR SUCH EMERGENCIES ONLY PENDING COMPLETION OF ARRANGEMENTS FOR CARE ELSEWHERE * * *.

"26. MEDICAL CARE NOT AUTHORIZED. MEDICAL CARE AND SERVICES SPECIFIED IN THIS SECTION SHALL NOT BE AUTHORIZED FOR ANY OF THE FOLLOWING:

"B. NERVOUS AND MENTAL DISORDERS EXCEPT FOR EMERGENCIES AS IN PARAGRAPHS 14B AND 24G.'

PARAGRAPH 19C, CHANGE 1, ARMY REGULATIONS 40-122, DATED OCTOBER 3, 1957, PROVIDES THAT CLAIMS FOR REIMBURSEMENT FOR AUTHORIZED CIVILIAN MEDICAL CARE PROVIDED SPOUSES AND CHILDREN IN THE CONTINENTAL UNITED STATES MAY BE SUBMITTED DIRECT TO THE APPROPRIATE MAJOR ARMY COMMANDER, WHO HAS JURISDICTION OVER THE GEOGRAPHICAL AREA IN WHICH THE TREATMENT WAS RENDERED FOR REVIEW AND DISPOSITION IN ACCORDANCE WITH INSTRUCTIONS ISSUED BY THE EXECUTIVE AGENT.

PARAGRAPH 6D, ARMY CIRCULAR 40-18, DATED OCTOBER 15, 1957, PROVIDES THAT CIVILIAN PHYSICIANS WHO ACCEPT AS PATIENTS DEPENDENTS WITH ACUTE EMOTIONAL DISORDERS HAVE THE RESPONSIBILITY OF DETERMINING WHETHER THE ACUTE EMOTIONAL DISORDER CONSTITUTES AN ACUTE EMERGENCY, AND WHETHER HOSPITALIZATION IS NECESSARY TO PROTECT THE LIFE, HEALTH OR WELL-BEING OF THE DEPENDENT.

PARAGRAPH 4 OF THE ODMC LETTER OF JANUARY 2, 1958, PROVIDES THAT THE JUDGMENT AND INTEGRITY OF THE ATTENDING PHYSICIAN MUST BE RELIED UPON TO DETERMINE WHEN THE ACUTE EMOTIONAL DISTURBANCE SUBSIDES AND HIS WORD WILL NOT BE QUESTIONED EXCEPT WHEN THERE IS EVIDENCE TO THE CONTRARY. LIKEWISE, THE JUDGMENT OF THE PHYSICIAN MUST BE RELIED UPON TO DETERMINE THE PROBABLE DURATION OF HOSPITALIZATION WHICH WILL BE REQUIRED FOR EACH INDIVIDUAL PATIENT. PARAGRAPH 5 OF THAT LETTER PROVIDES THAT BILLS MAY BE PAID UNDER THE MEDICAL CARE PLAN WITHOUT FURTHER REFERENCE IF THE PHYSICIAN STATES THE CONDITION WAS ONE OF ACUTE EMOTIONAL DISORDER CONSTITUTING AN EMERGENCY REQUIRING HOSPITALIZATION FOR THE LIFE, HEALTH OR WELL-BEING OF THE PATIENT, REGARDLESS OF PSYCHIATRIC DIAGNOSIS. THIS LATTER PROVISION APPEARS TO CONTEMPLATE ALLOWANCE OF A CLAIM ON THE BASIS OF A PHYSICIAN'S STATEMENT AS TO THE QUALIFYING DEGREE OF EMERGENT DISABILITY. THE FACT THAT A DEPENDENT HAD SUFFERED FROM MENTAL DISORDERS IN THE PAST, WOULD NOT SEEM TO BAR HOSPITALIZATION AND TREATMENT AT GOVERNMENT EXPENSE IF THAT CONDITION SUDDENLY BECAME WORSE TO THE EXTENT OF CONSTITUTING A THREAT TO THE LIFE AND HEALTH OF SUCH DEPENDENT.

THIS CASE INVOLVES SERVICES FURNISHED FOR AN ACUTE EMOTIONAL DISORDER IN CONNECTION WITH WHICH THE ATTENDING PHYSICIAN HAS CERTIFIED IN STATEMENTS DATED OCTOBER 20, 1958, AND OCTOBER 13, 1959, THAT AN EMERGENCY EXISTED REQUIRING IMMEDIATE HOSPITALIZATION OF THE PATIENT SINCE SHE WAS ,SUICIDALLY OBSESSED" AND "IT WAS FELT DANGEROUS TO TEMPORIZE.' HE STATED FURTHER THAT MRS. SIDMORE'S CONDITION BECAME ACUTE ON AUGUST 5, 1958. SEEMS APPARENT THAT SHE COULD NOT HAVE BEEN COMMITTED TO A MENTAL INSTITUTION IMMEDIATELY AND IT APPEARS THAT THE TREATMENTS SHE RECEIVED IN THE HOSPITAL MADE THAT ACTION UNNECESSARY. UNDER THE POLICY PREVAILING AT THE TIME THIS CASE AROSE PAYMENT FOR IN-PATIENT TREATMENT OF ACUTE EMOTIONAL DISORDERS WHEN CERTIFIED TO BE AN EMERGENCY WAS AUTHORIZED, GENERALLY, FOR A MAXIMUM OF 21 DAYS OR UPON TERMINATION OF THE ACUTE EMERGENCY WHICHEVER WAS THE LESSER. SEE PARAGRAPHS 5 AND 6, CDMC LETTER NO. 2-/58).

ACCORDINGLY, PAYMENT IN THE AMOUNT APPROVED ($790.33) FOR THE 21 DAY PERIOD FROM AUGUST 5 TO 25, 1958, WOULD APPEAR TO BE PROPER, IF OTHERWISE CORRECT. THE SUBMITTED VOUCHER AND ACCOMPANYING PAPERS ARE RETURNED HEREWITH.