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6.5 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?

Question
6.5 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?
Effective Date
Answer

Yes. You can request reimbursement for past out-of-pocket medical expenses you paid as a result of your eligible condition(s) if they were paid before the date that the WTC Health Program certified your condition(s). The VCF will not reimburse for expenses you incur after your condition was certified if you decide to have your conditions treated by a non-WTC Health Program physician, or to have your prescriptions filled by an unaffiliated pharmacy.

Because claims for reimbursement of out-of-pocket medical expenses require the submission and review of significant documentation establishing that the claimed medical expense was related to your eligible condition and that you personally paid for the expense out of pocket, processing these claims takes time and can delay your award. As a result, the VCF has established specific criteria about when and how you should submit your claim for medical expenses.

  • In a personal injury claim, the claim for medical expenses must be submitted as a compensation amendment to your claim and only after you have received your initial award determination. This allows the VCF to issue your initial award determination more quickly, since we are not spending time during our initial review to verify each claimed medical expense.
  • In a deceased claim, the claim for medical expenses must be submitted as part of your initial claim. This is because for deceased claims, you generally will not be permitted to amend your claim after the VCF finalizes substantive review of the compensation claim.
  • The total amount of the claimed medical expenses due to eligible conditions must exceed $5,000.
  • The claim must be submitted with the required documentation and in the required format as explained in these instructions.

The Special Master may exercise discretion to waive one or more of these requirements as appropriate based on individual claimant circumstances. If you wish to seek a waiver, please contact the VCF Helpline.

FAQ Status
Updated
Question Number
5