Can I Get Reimbursed for Medical Expenses That I Paid out-of-Pocket and Were Not Covered by the WTC Health Program or Reimbursed by My Insurance?
If you are seeking compensation for the expenses and impacts you incurred because of exposure to the toxic substances present at the terrorist attack sites on 9/11 from the September 11th Victim Compensation Fund (VCF), can you get reimbursed for medical expenses you paid out-of-pocket that neither the WTC Health Program nor your insurance covered?
As it turns out, yes, you can. However, there are rules as to when you should submit a claim for medical expenses.
An experienced 9/11 benefits attorney can help you prepare your VCF claim, including ensuring you have all of the documentation you need to submit with the claim.
Seeking Benefits Through the VCF and the WTC Health Program
In the early days after the terrorist attacks in New York City, at the Pentagon, and the crash site in Shanksville, PA, it quickly became apparent that the federal government needed to assist the many people whom the attacks severely harmed or exposed to toxins. Rescue, recovery, and cleanup workers also needed help. In fact, so did people who just lived, worked, or went to school in the exposure zone.
The original VCF provided this funding until 2004. Years later, as many conditions such as breathing and digestive disorders (plus many cancers) caused by the toxic exposure at these sites continued to be diagnosed in the first responders and survivors, the government reinstated and expanded the VCF program with new guidelines. It also established the WTC Health Program, which provides healthcare and monitoring to individuals who were at one of the attack sites during specific dates on and during the ten months after September 11, 2001.
Currently, the VCF provides compensation to eligible individuals who were present in the 9/11 Crash Site Area (all of Lower Manhattan south of Canal Street and anywhere the debris was handled) and who have a 9/11-related cancer or other medical condition that has been certified by the WTC Health Program. Seeking certification of a medical condition by the WTC Health Program requires applying for the program and receiving a medical evaluation at one of the program’s designated facilities in New York City, or by one of its providers in the nationwide network of providers located across the country.
Claiming Reimbursement of Medical Expenses You Paid Out-of-Pocket
The VCF will compensate you for out-of-pocket medical expenses related to your 9/11-associated condition that you incurred before your condition was certified by the WTC Health Program and that weren’t reimbursed by insurance.
However, the VCF does not reimburse out-of-pocket medical expenses that occurred after the WTC Health Program certified your condition if you opt to seek treatment of your condition from a non-participating physician who is outside of the program’s affiliation.
Additionally, the VCF will not reimburse you for prescription costs filled by a non-participating pharmacy.
To receive the reimbursement, you must satisfy the following criteria:
- Your out-of-pocket expenses are more than $5,000.
- You incurred expenses for prescribed medication or medical equipment, doctor visits, diagnostic tests, surgeries, or other medical expenses related to your 9/11-associated condition.
- The expenses were NOT associated with travel for medical treatment such as the cost of gas or lodging. The VCF will also not reimburse insurance premiums, investigational or holistic treatment, wigs, home modifications, water filters, or air filters.
- Your insurance or a secondary payer evaluated the expenses and did not pay them. The VCF will not consider expenses that have not yet been submitted for evaluation by an insurance company, worker’s compensation program, or other applicable benefit programs.
How and when you submit the documentation necessary to prove your out-of-pocket expenses depends on the circumstances of your situation. Here is how it works with different scenarios.
With Personal Injury Claims
If you seek reimbursement for medical expenses, you must wait and submit your documentation as an amendment to your VCF claim after you have received your initial award determination.
You must submit the claim as an amendment because you must provide a substantial amount of documentation about the expenses and how they related to your 9/11-associated medical condition.
Review of this documentation can take quite a bit of time, resulting in a delay of your initial award. By submitting the request for reimbursement as an amendment, the VCF administrators can issue an initial decision on your claim more quickly.
To amend your claim to seek reimbursement of out-of-pocket medical expenses, you can log into your VCF account online and follow these steps:
- Click on “Compensation Change”
- Check the box for “Reimbursement for Out-of-Pocket Medical Expenses”
- In the text box, provide the details of the amendment or changes you are requesting. Be sure to follow the online instructions completely. It is also helpful to include the file names of the documentation files you are uploading in the text box
- Upload the associated files that contain documentation required to prove your out-of-pocket expenses
- Click “Submit Amendment”
Required documents for amending your claim that you must submit along with the amendment include:
- Documentation that lists the amount you were billed, the service provider, the date of service, and proof that you paid the expense out-of-pocket.
- Documentation that demonstrates the relationship between the claimed expenses and your medical condition.
If you fail to provide all necessary documentation to prove you paid your expenses out-of-pocket and that they related to your 9/11 eligible condition, the VCF will deny your amendment and request for reimbursement.
You also must download, fill out, and submit the Medical Expense Worksheet, which identifies all out-of-pocket medical expenses.
Use the following steps to fill out the worksheet:
- Enter your 7-digit claim number, including any leading zeros.
- Enter your full name, or the victim’s name if you are not the victim.
- Enter the name of your insurance carrier or secondary payer as applicable.
- Enter each expense on an individual row on the worksheet. Do not lump expenses together. For each expense, you need a date of service, the provider’s name, a short description of the procedure that generated the expense, your related certified medical condition, and the amount of the expense that you paid out-of-pocket.
If you do not include a completed worksheet with your submission, the VCF can deny your request.
With Deceased Claims
Because the VCF generally does not allow the amendment of a deceased claim, to obtain reimbursement for out-of-pocket medical expenses, you must submit these expenses as part of your initial claim.
With Pending Claims or Amendments
If you already filed a claim for medical expenses as part of your initial personal injury claim for compensation, the VCF will not review any new amendments as part of your initial claim. Instead, the VCF asks that you wait until after you receive your initial award determination and have the opportunity to review whether you have at least $5,000 in eligible expenses.
Haven’t Filed a Claim for Your Certified Condition?
If you haven’t yet filed a VCF claim for compensation of the expenses and psychological impacts you incurred from your WTC Health Program-certified condition, you have a registration deadline.
On July 29, 2021, all individuals who had an eligible medical condition certified by the WTC Health Program before July 29, 2019, must register with the VCF to reserve the right to file a claim for compensation in the future. Additionally, if you intend to file a deceased claim for compensation due to the death of a loved one before July 29, 2019, you must also register with the VCF by July 29, 2021. If you (or a deceased family member) never treated at the WTC Health Program, you have two years from date that the WTC Health Program certifies any health condition as eligible for treatment, including for deceased claims.
Individuals who obtained certification of their eligible 9/11-related medical condition after July 29, 2019, have two years after the latest date listed on the certification to register to file a claim. Registering with the VCF, filing a compensation claim, and filing an amendment to a claim are different.
To register with the VCF, click on “Register,” located in the upper right corner of the VCF website, and follow online instructions. Registration requires only basic information, including name, address, phone number, Social Security number, and date of birth.
Once you registered with the VCF, it reserves your right to file a claim at any time until October 1, 2090.
To file a claim, you must submit:
- Authorization of the release of medical records. This allows the VCF to go to the WTC Health Program directly to ensure that you have a certified eligible condition.
- A signature page that allows the VCF to investigate your claim by seeking information to support your claim from other sources, such as your employer, union, or worker’s compensation program. The signature page also is the acknowledgment of your understanding that, by accepting compensation from the VCF, you are waiving your right to file a lawsuit seeking compensation for 9/11-related injuries.
- Proof of presence at a 9/11 attack site during the required time and for the required exposure periods as outlined in the VCF eligibility guidelines. For example, the New York City exposure zone runs south of Canal Street, river to river, and from the Hudson River to the intersection of Canal Street and East Broadway. The exposure zone also includes East Broadway to Clinton Street, Clinton Street to the East River, and any of the routes associated with debris removal. You must be able to prove that you were there at any point between September 11, 2001, and May 30, 2002, as well as showing how long you were in the exposure area. The VCF accepts a wide variety of documents as proof of presence, including employer letters, worker injury reports, medical reports, leases or mortgage documents, tax returns, or school records.
Contrary to popular belief, the benefits provided through the WTC Health Program are not only for police officers and firefighters who responded to 9/11.
Individuals who may seek WTC Health Program benefits also include:
- Residents living or working in lower Manhattan at the time of the terrorist attack.
- Students or teachers who were at schools located in the exposure zone during the attack or in the months following.
- Construction workers who cleaned up after the attack.
- Emergency and communications personnel working in the area during recovery efforts.
- Out-of-state responders who came to the area to assist with rescue, recovery, and cleanup.
- The family members of individuals who were exposed to the toxins at the attack sites and later died of a 9/11-related medical condition.