What is a Presumptively Compensable Expense?

When you file a claim for compensation with the September 11th Victim Compensation Fund (VCF), you normally have to include documents that demonstrate that each expense is related to one of your eligible conditions. There are some expenses, however, that the VCF will accept without the need to prove a connection to the related condition because they have been determined to be commonly necessary and directly related to a specific 9/11-related condition. These are called presumptively compensable expenses. Because they are "presumptively" eligible for compensation, these expenses are generally accepted without the need for extensive documentation or justification. This can help to streamline the claims process and ensure that claimants receive timely and fair compensation.

The VCF has a number of important rules that govern reimbursement for medical expenses. First, out-of-pocket medical expenses can only be requested for amounts spent before the 9/11 conditions was certified by the WTC Health Program. Second, a request for reimbursement of past medical expenses must be submitted as an amendment after the VCF issues the initial award for non-economic (pain and suffering) losses. Third, the 9/11-related past out-of-pocket expenses must total at least $5,000. 

How the VCF Categorizes Presumptively Compensable Expenses

The VCF has a specific process for categorizing and approving expenses related to a claim for compensation. The VCF recognizes that claimants may incur various costs due to their 9/11-related conditions, and it aims to simplify the reimbursement process for certain common and necessary expenses. The categories are based on the type of condition, and presumptively compensable expenses include specific medications and procedures. Conditions that have presumptively compensable expenses include obstructive airway disease, interstitial lung disease, gastroesophageal reflux disease, upper respiratory disease, and prostate cancer. 

Expenses the VCF Considers "Presumptively Compensable"

The expenses the VCF considers “presumptively compensable” can be broken into two categories: presumptively compensable medications and presumptively compensable procedures. The VCF maintains a list of the medications and procedures that are presumptively compensable for each of the conditions mentioned above. For example, for gastroesophageal reflux disease, the following procedures are considered presumptively compensable: Barium Swallow, Esophagogastroduodenoscopy (EGD), Laryngopharyngeal Endoscopy, Pathology (esophagus, gastric, and duodenum specimens), and upper GI Series; and the following medications are considered presumptively compensable: esomeprazole (Nexium), famotidine (Pepcid), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), ranitidine (Zantac) and proton pump inhibitors. Other conditions have their own lists of presumptively compensable medications and procedures. Please note these are subject to change and it is important to ensure you are referring to the most recent chart.

Utilizing the VCF's Medical Expense Worksheet

To assist claimants in organizing and submitting their medical expenses, the VCF provides a Medical Expense Worksheet. This worksheet is an Excel file designed to help claimants itemize their expenses and ensure that all relevant costs are accounted for and all necessary information is provided. Even if your expense is presumptively compensable, you will still need to add it to this worksheet and provide some documentation that demonstrates the amount of the expense. Instructions are included in the worksheet, along with a sample for reference. 

Before filling out the worksheet, gather all relevant medical bills, receipts, and other documentation related to your expenses. Use the worksheet to list each expense individually along with all corresponding information. You will need to list your insurance provider and VCF claim number, if applicable. For each expense, you will need to provide the following information: the date of service; the name of the related eligible condition; the date of certification of related eligible condition; the name of the doctor, facility or pharmacy; a short description of the procedure, treatment or related expense; the amount paid by the claimant;  supporting documentation for any expense that is not presumptively compensable that shows relationship to the eligible condition; and supporting documentation that shows proof of payment (for the final two items, include them in the  Supporting Documentation Packet and then list the page number on the Medical Expense Worksheet where they can be found). Attach the completed worksheet to your VCF claim submission, along with the Supporting Documentation Packet.

Work with a Dedicated VCF Attorney

Understanding the concept of presumptively compensable expenses and how to track, document, and report related expenses is essential for anyone filing a VCF claim– but you don’t have to do it alone. Seeking the assistance of a knowledgeable VCF attorney can significantly ease the claims process and help claimants maximize their financial compensation. A knowledgeable VCF attorney can provide guidance on the types of expenses that are likely to be compensated, assist in gathering and organizing necessary documentation, and represent the claimant at VCF hearings. An attorney ensures that the claimant’s submission is as thorough and precise as possible. 

If you were affected by the 9/11 attacks and need help navigating the VCF claims process, reach out to one of the dedicated 9/11 attorneys at Hansen and Rosasco, LLP. With over 20 years of experience representing 9/11 VCF claims, our law firm is committed to providing compassionate and effective representation that is tailored to your individual needs. Contact us today to find out more about how our attorneys can help you get the maximum compensation you are entitled to.