B-51248, AUGUST 21, 1945, 25 COMP. GEN. 207

B-51248, AUGUST 21, 1945, 25 COMP. GEN. 207

MEDICAL TREATMENT - SCOPE OF "EMERGENCY MEDICAL CARE" AUTHORITY THE EXPENSE OF FITTING A SELECTIVE SERVICE REGISTRANT WITH A DENTAL BRIDGE SOME TIME AFTER HIS RETURN HOME FROM AN INDUCTION STATION AT WHICH HE HAD BEEN TREATED FOR A DENTAL INJURY SUFFERED WHILE THERE MAY NOT BE REGARDED AS AN EXPENSE OF "EMERGENCY MEDICAL CARE" FOR WHICH FUNDS APPROPRIATED BY THE NATIONAL WAR AGENCY APPROPRIATION ACT, 1945, ARE AVAILABLE, EVEN THOUGH INSTALLATION OF THE BRIDGE MAY HAVE BEEN DESIRABLE OR NECESSARY FROM A MEDICAL VIEWPOINT. FUNDS APPROPRIATED TO THE SELECTIVE SERVICE SYSTEM FOR "EMERGENCY MEDICAL CARE" OF REGISTRANTS SUFFERING ILLNESS OR INJURY WHILE UNDER SELECTIVE SERVICE JURISDICTION ARE NOT AVAILABLE FOR DEFRAYING THE COST OF PROSTHETIC APPLIANCES OR PLASTIC SURGERY IN OTHERWISE PROPER CASES UNLESS IT BE SHOWN THAT COMPETENT MEDICAL OPINION IS TO THE EFFECT THAT AN EMERGENCY CONTINUED AND THAT EMERGENCY MEDICAL CARE OF THE ILLNESS OR INJURY INVOLVED REQUIRES THE FURNISHING OF SUCH APPLIANCES OR SURGERY.

COMPTROLLER GENERAL WARREN TO THE DIRECTOR OF SELECTIVE SERVICE, AUGUST 21, 1945:

REFERENCE IS MADE TO YOUR LETTER OF JULY 20, 1945, AS FOLLOWS:

THE NATIONAL WAR AGENCY APPROPRIATION ACT, 1945, PROVIDES THAT FUNDS OF THE SELECTIVE SERVICE SYSTEM SHALL BE AVAILABLE, INTER ALIA, FOR:

"EXPENSES OF EMERGENCY MEDICAL CARE, INCLUDING HOSPITALIZATION, OF REGISTRANTS WHO SUFFER ILLNESS OR INJURY, AND THE TRANSPORTATION, AND BURIAL, OF THE REMAINS OF REGISTRANTS WHO SUFFER DEATH, WHILE ACTING UNDER ORDERS ISSUED UNDER THE SELECTIVE SERVICE LAW BUT SUCH BURIAL EXPENSES SHALL NOT EXCEED $150 IN ANY ONE CASE; "

THIS PROVISION WAS FIRST INCORPORATED IN OUR APPROPRIATION LANGUAGE BY P.L. 279, 78TH CONGRESS, APPROVED APRIL 1, 1944. PRIOR TO SUCH AUTHORIZATION, THE FUNDS OF THIS AGENCY WERE NOT AVAILABLE TO PROVIDE MEDICAL CARE FOR INJURED REGISTRANTS (SEE YOUR DECISION NO. B-16393, DATED MAY 14, 1941.)

TO IMPLEMENT THE GENERAL AUTHORITY CONFERRED BY THE QUOTED APPROPRIATION LANGUAGE, AND PURSUANT TO THE PROVISIONS OF SECTION 10 (A) (1) OF THE SELECTIVE TRAINING AND SERVICE ACT OF 1940, AS AMENDED, SECTION 608.51 OF SELECTIVE SERVICE REGULATIONS WAS PROMULGATED DECEMBER 8, 1944, AND IS CURRENTLY EFFECTIVE. A COPY OF THIS REGULATION IS ATTACHED FOR YOUR CONVENIENCE, AS WELL AS A COPY OF SELECTIVE SERVICE F.P.A. BULLETIN FISCAL CONTROL 3-5, ISSUED FOR THE ADMINISTRATIVE GUIDANCE OF THE PERSONNEL OF THE SYSTEM CHARGED WITH THE APPLICATION OF THE LAW AND REGULATIONS IN SPECIFIC CASES.

IT WILL BE NOTED FROM PARAGRAPH (D) OF THE REGULATION THAT THE ALLOWANCE OR DISALLOWANCE OF CLAIMS FOR EMERGENCY MEDICAL CARE AND HOSPITALIZATION IS FOR THE DETERMINATION OF THE STATE DIRECTOR OF SELECTIVE SERVICE OF THE STATE IN WHICH THE EXPENSES WERE INCURRED. SUCH CLAIMS, HOWEVER, MAY BE SUBMITTED TO SELECTIVE SERVICE HEADQUARTERS FOR AN ADVISORY OPINION. UNDER THIS PRACTICE, I PRESENTLY HAVE BEFORE ME A CLAIM FOR $150, PRESENTED BY A REGISTRANT, MELBERT E. LEHR, TO THE STATE DIRECTOR OF NORTH DAKOTA, FOR REIMBURSEMENT OF THE AMOUNT PAID TO A CIVILIAN DENTIST FOR INSTALLATION OF A REMOVABLE DENTURE OR BRIDGE. THE STATE DIRECTOR HAS INDICATED ADMINISTRATIVE APPROVAL OF THE CLAIM, SUBJECT TO ADVICE FROM HIS HEADQUARTERS, FOR THE AMOUNT OF $32.50. THE FACTS OF THE CASE ARE AS FOLLOWS:

THE REGISTRANT, PURSUANT TO AN ORDER TO REPORT FOR A PREINDUCTION PHYSICAL EXAMINATION, ARRIVED AT THE ARMED FORCES INDUCTION STATION AT FORT SNELLING, MINNESOTA, ON FEBRUARY 8, 1945. WHILE AT THE INDUCTION STATION HE FAINTED, FELL FORWARD AND STRUCK HIS FACE, CAUSING SUCH INJURY TO THE UPPER FOUR INCISOR TEETH THAT HE WAS REMOVED TO THE STATION HOSPITAL WHERE THE INJURED TEETH WERE REMOVED. THE REGISTRANT WAS SENT HOME AS SOON AS HE WAS SUFFICIENTLY RECOVERED TO TRAVEL, WITHOUT FURTHER DENTAL TREATMENT, AND SHORTLY THEREAFTER CONSULTED A CIVILIAN DENTIST IN JAMESTOWN, NORTH DAKOTA. THE LATTER FOUND A PURULENT DRAINAGE FROM THE REGISTRANT'S GUMS WHICH PREVENTED IMMEDIATE FITTING OF A DENTURE, BUT HE THEN RECOMMENDED AND SUBSEQUENTLY INSTALLED A METALLIC BRIDGE. THE DATE OF INSTALLATION IS NOT SPECIFIED IN THE FILE, BUT WAS PRIOR TO MAY 1945, AND PRESUMABLY WAS DONE AS SOON AS THE CONDITION OF THE REGISTRANT'S GUMS WOULD PERMIT. THE REGISTRANT SUBMITS A RECEIPTED BILL EVIDENCING PAYMENT TO THE DENTIST OF $150 FOR THE DENTAL SERVICES AND MATERIALS FURNISHED.

THE AMOUNT FOR WHICH THE STATE DIRECTOR HAS APPROVED THE CLAIM, $32.50, REFLECTS THE AMOUNT PRESCRIBED BY ME AS A REASONABLE FEE PURSUANT TO THE ATTACHED BULLETIN, SINCE THE FEE SCHEDULE INCLUDED IN THE BULLETIN DOES NOT COVER THE ITEM IN QUESTION. IN SUCH CASES, THE FEE PRESCRIBED BY ME IS NORMALLY BASED ON THE SCHEDULE OF FEES APPROVED BY THE VETERANS' ADMINISTRATION, ALTHOUGH IT IS CONTEMPLATED THAT A HIGHER OR LOWER FEE MIGHT BE PRESCRIBED IN A PARTICULAR CASE IF THE CIRCUMSTANCES JUSTIFY SUCH DEPARTURE.

THIS CLAIM PRESENTED A QUESTION OF INTERPRETATION AND APPLICATION OF THE APPROPRIATION LANGUAGE ON WHICH NO EXACT OR CONTROLLING PRECEDENT HAS BEEN BROUGHT TO MY ATTENTION.

THE STATUTE SPECIFIES "EMERGENCY MEDICAL CARE" AND THE QUESTION IN THE PRESENT CASE ARISES OUT OF THE WORD "EMERGENCY," SINCE THE TERM "MEDICAL CARE" CERTAINLY SEEMS BROAD ENOUGH TO COVER PROFESSIONAL SERVICES NORMALLY RENDERED BY DENTISTS AS DISTINGUISHED PROFESSIONALLY FROM DOCTORS OF MEDICINE OR SURGERY. I AM INFORMED THAT IN MODERN DENTAL PRACTICES THE REPLACEMENT BY ARTIFICIAL MEANS OF EXTRACTED TEETH IS REGARDED AS NECESSARY, AND SHOULD BE DONE IMMEDIATELY, OR AS SOON THEREAFTER AS POSSIBLE, IN ORDER TO AVOID THE RISK OF INFECTION OR DETERIORATION OF THE GUMS AND REMAINING TEETH.

FROM THE BROADER ADMINISTRATIVE STANDPOINT, HOWEVER, IT IS MY VIEW THAT THE SENSE AND APPARENT PURPOSE OF THE LAW IS TO ENABLE THE USE OF SELECTIVE SERVICE FUNDS IN PROVIDING PAYMENT FOR MEDICAL CARE OF REGISTRANTS WHO SUFFER ILLNESS OR INJURY OF AN EMERGENCY NATURE WHILE AWAY FROM PRIVATE PURSUITS UNDER THE GENERAL DIRECTION OF SELECTIVE SERVICE, AND TO PROVIDE SUCH CARE IN SUCH MEASURE AND FOR SUCH REASONABLE PERIOD AS APPEARS MEDICALLY ADVISABLE OR NECESSARY TO RESTORE THE REGISTRANT AS NEARLY AS POSSIBLE TO HIS CONDITION AT THE TIME THE ILLNESS OR INJURY OCCURRED. PERMANENT CARE, OR CARE BEYOND THE POINT AT WHICH IT BECOMES APPARENT THAT TREATMENT MUST BE PROLONGED INDEFINITELY, IS, OF COURSE, NOT CONTEMPLATED IN ANY INSTANCE.

YOUR ADVICE IS REQUESTED IN RESPONSE TO THE FOLLOWING QUESTIONS:

1. WILL YOU FEEL REQUIRED TO OBJECT TO THE USE OF SELECTIVE SERVICE FUNDS IN PAYMENT OF THE ABOVE DESCRIBED CLAIM TO THE EXTENT OF $32.50 WHICH HAS BEEN ADMINISTRATIVELY APPROVED BY THE STATE DIRECTOR OF SELECTIVE SERVICE OF NORTH DAKOTA?

2. ASSUMING THE OCCURRENCE OF AN ILLNESS OR INJURY WHICH WOULD JUSTIFY THE USE OF SELECTIVE SERVICE FUNDS TO PROVIDE EMERGENCY MEDICAL CARE, ARE SUCH FUNDS AVAILABLE TO PROVIDE SUCH TREATMENT AS THE FURNISHING OF PROSTHETIC APPLIANCES OR PLASTIC SURGERY WHERE THE NEED FOR SUCH TREATMENT IS DIRECTLY CAUSED BY THE ILLNESS OR INJURY AND IS A PART OF THE PROPER AND CUSTOMARY CARE OR TREATMENT FOR SUCH AN ILLNESS OR INJURY UNDER ESTABLISHED MEDICAL PRACTICE?

THE PROVISION OF THE NATIONAL WAR AGENCY APPROPRIATION ACT, 1945, PUBLIC LAW 372, 78TH CONGRESS, 58 STAT. 544, QUOTED IN YOUR LETTER, IS PREFACED BY THE WORDS "UNDER SUCH RULES OR REGULATIONS AS MAY BE PRESCRIBED BY THE DIRECTOR OF SELECTIVE SERVICE.' IN THE REGULATION REFERRED TO, SECTION 608.51, SELECTIVE SERVICE REGULATIONS, IT IS PROVIDED, IN PART, AS FOLLOWS:

(B) THE TERM "EMERGENCY MEDICAL CARE, INCLUDING HOSPITALIZATION" AS USED IN THIS SECTION SHALL BE CONSTRUED TO MEAN THAT NORMALLY SUCH MEDICAL CARE OR HOSPITALIZATION MUST BE RENDERED PROMPTLY AFTER OCCURRENCE OF THE ILLNESS OR INJURY AS A RESULT OF WHICH IT IS REQUIRED, AND THAT DISCHARGE BY A PHYSICIAN OR FACILITY SUBSEQUENT TO SUCH MEDICAL CARE OR HOSPITALIZATION SHALL PRIMA FACIE TERMINATE THE PERIOD OF EMERGENCY. AND IN SECTION 4 OF SELECTIVE SERVICE F.P.A. BULLETIN, FISCAL CONTROL 3-5, IT IS EXPLAINED THAT---

THE PHRASE "NORMALLY SHALL BE CONSTRUED TO MEAN THAT SUCH MEDICAL CARE OR HOSPITALIZATION MUST BE RENDERED PROMPTLY" INCLUDED IN PARAGRAPH (B) OF SECTION 608.51 (CORRECT QUOTATION IS "SHALL BE CONSTRUED TO MEAN THAT NORMALLY SUCH MEDICAL CARE OR HOSPITALIZATION MUST BE RENDERED PROMPTLY") IS INTENDED TO INDICATE THAT THE BASIC ADMINISTRATIVE INTENT IN OBTAINING SUCH ENABLING LEGISLATION WAS TO MAKE IT POSSIBLE TO CARE FOR EMERGENCY ILLNESS OR INJURY * * * OF A REGISTRANT WHILE HE WAS UNDER THE DIRECT ADMINISTRATIVE SUPERVISION OF SELECTIVE SERVICE. * * * AND THAT THE TERM-

"PRIMA FACIE" FOR PURPOSES OF THESE REGULATIONS IS INTENDED TO MEAN THAT THE PERIOD OF RESPONSIBILITY OF SELECTIVE SERVICE, IN THE ABSENCE OF CONVINCING EVIDENCE TO THE CONTRARY, SHALL NORMALLY BE PRESUMED TO END AT SUCH TIME AS A REGISTRANT IS GIVEN WHATEVER TREATMENT THE INCIDENT IN THE EMERGENCY APPEARS TO DEMAND AND IS THEREAFTER PRONOUNCED BY AN ATTENDING PHYSICIAN OR FACILITY TO REQUIRE NO FURTHER SUCH TREATMENT FOR THAT EMERGENCY. THAT A DISCHARGE MAY BE CONDITIONAL ON SOME FUTURE DEVELOPMENT OR NEED OR THAT A DISCHARGE MAY BE AS THE RESULT OF A FAULTY MEDICAL DIAGNOSIS IS FOR THE CONSIDERATION OF THE STATE DIRECTOR MAKING THE DETERMINATION IN THE INDIVIDUAL CASE WHICH HE IS CONSIDERING.

THE REGULATION AND RELATED INSTRUCTIONS APPEAR TO BE BASED UPON A REASONABLE INTERPRETATION AND TO BE CONSISTENT WITH THE EXPRESSED INTENT OF THE LEGISLATION. THERE IS NOTHING IN THE LEGISLATIVE HISTORY OR IN THE CONTEXT OF THE LAW THAT WOULD INDICATE IN ANY WAY A USE OF THE WORD "EMERGENCY" IN OTHER THAN ITS NORMAL AND CUSTOMARY SENSE--- THAT IS, TO MEAN, AS DEFINED BY WEBSTER,"AN UNFORESEEN OCCURRENCE OR COMBINATION OF CIRCUMSTANCES WHICH CALLS FOR IMMEDIATE ACTION OR REMEDY; PRESSING NECESSITY, EXIGENCY"--- OR THAT IT IS EMPLOYED IN THE LEGISLATION IN A MANNER THAT COULD BE CONSIDERED AS AMBIGUOUS.

UNDER THE CIRCUMSTANCES, IT APPEARS THAT, IN ASCERTAINING TO WHAT EXTENT CARE OR TREATMENT PROPERLY MAY BE CHARGED TO THE GOVERNMENT IN ANY CASE, IT IS NECESSARY TO DETERMINE WHEN THE REQUIREMENTS OF EMERGENCY CARE HAVE BEEN SATISFIED. IN THIS CONNECTION, IT IS REALIZED THAT SUCH DETERMINATIONS ARE ESSENTIALLY TECHNICAL AND THAT, THEREFORE, RELIANCE MUST BE PLACED UPON THE STANDARDS OF TREATMENT ACCEPTED IN SUCH CASES BY THE MEDICAL PROFESSION.

IN THE CASE OF MELBERT E. LEHR, IT APPEARS THAT WHEN HE WAS TREATED AT THE INDUCTION STATION AND THEN SENT HOME--- EVEN THOUGH FURTHER MEDICAL ATTENTION MAY HAVE BEEN NECESSARY AT A LATER TIME--- THE EMERGENCY WAS OVER. ALTHOUGH YOUR STATEMENT THAT "IN MODERN DENTAL PRACTICE THE REPLACEMENT BY ARTIFICIAL MEANS OF EXTRACTED TEETH IS REGARDED AS NECESSARY" HAS BEEN GIVEN CAREFUL NSIDERATION,"EMERGENCY" MEDICAL CARE OBVIOUSLY DOES NOT INCLUDE ALL "NECESSARY" CARE; AND THE INSTALLATION OF A METALLIC BRIDGE IN MR. LEHR'S CASE, AFTER HIS RETURN HOME, HOWEVER DESIRABLE OR NECESSARY FROM A MEDICAL VIEWPOINT, DOES NOT APPEAR TO HAVE BEEN UNDER CIRCUMSTANCES QUALIFYING AS ,EMERGENCY" AND REQUIRING EMERGENCY MEDICAL CARE. THE REGULATIONS AND EXPLANATIONS QUOTED ABOVE SUPPORT THIS VIEW. ACCORDINGLY, YOU ARE ADVISED THAT THE FACTS SHOWN ON THE PRESENT RECORD DO NOT JUSTIFY A USE OF SELECTIVE SERVICE SYSTEM FUNDS TO PAY FOR ANY PART OF THE EXPENSES OF SUCH REPLACEMENT IN HIS CASE.

WITH RESPECT TO WHETHER THE FUNDS INVOLVED ARE AVAILABLE TO PROVIDE TREATMENT SUCH AS THE FURNISHING OF PROSTHETIC APPLIANCES OR PLASTIC SURGERY GENERALLY IN OTHERWISE PROPER CASES WHERE ,THE NEED FOR SUCH TREATMENT IS DIRECTLY CAUSED BY THE ILLNESS OR INJURY AND IS A PART OF THE PROPER AND CUSTOMARY CARE OR TREATMENT FOR SUCH AN ILLNESS OR INJURY UNDER ESTABLISHED MEDICAL PRACTICE," I HAVE TO ADVISE THAT THE SAME PRINCIPLE IS APPLICABLE. THAT IS TO SAY, THE AVAILABILITY OF SELECTIVE SERVICE SYSTEM APPROPRIATIONS FOR DEFRAYING THE COST OF PROSTHETIC APPLIANCES OR PLASTIC SURGERY MUST BE DETERMINED BY THE JUSTIFICATION EXISTING IN ANY PARTICULAR CASE FOR FURNISHING THEM AS "EMERGENCY MEDICAL CARE.' EXPENDITURES FALLING WITHIN THAT CATEGORY NECESSARILY MUST BE QUESTIONED UNLESS IT BE SHOWN THAT COMPETENT MEDICAL OPINION IS TO THE EFFECT THAT AN EMERGENCY CONTINUED AND THAT EMERGENCY MEDICAL CARE OF THE ILLNESS OR INJURY INVOLVED CLEARLY REQUIRED THE FURNISHING OF SUCH APPLIANCES OR SURGERY.