The short answer
CHAMPVA doesn't cover care for a work-related injury or illness when workers' compensation or a similar plan is payable, even if you never filed a workers' comp claim. Once those benefits run out, CHAMPVA may cover the care if it's otherwise covered. VA may send Form 10-7959D asking about the injury.
What's the rule?
38 CFR 17.272(a)(2) excludes services and supplies for a work-related injury or illness when benefits are payable under workers' compensation or a similar protection plan, whether or not you applied for or received them.
The exception: once those benefits are exhausted, CHAMPVA may consider the care if it's otherwise covered.
Is this like other insurance paying first?
No. With most other insurance, CHAMPVA pays what's left after the other plan. With workers' comp, CHAMPVA doesn't pay at all while workers' comp is payable. Don't expect CHAMPVA to pick up the balance.
What if you didn't file for workers' comp?
The exclusion still applies. It depends on whether benefits are payable, not whether you claimed them. Skipping the workers' comp claim doesn't shift the bill to CHAMPVA.
What if workers' comp denied it?
Keep the decision. It's important evidence, but it doesn't automatically mean CHAMPVA pays. CHAMPVA still decides whether the exclusion applies and whether the care is covered.
Why might VA send Form 10-7959D?
VA Form 10-7959D, the Potential Liability Claim, is used when a claim looks like it involves an injury or a possible work-related illness. It asks about:
- the diagnosis,
- when, where, and how it happened,
- whether it was at work,
- your employer or insurer and policy number,
- witnesses, and
- your attorney, if you have one.
The form says providing the information is voluntary, but leaving it out can delay or lead to denial. VA uses it partly because 38 CFR 17.278 says VA pursues recovery of medical costs when someone else is responsible.
What should you do?
- Figure out whether workers' comp applies to the injury or illness.
- Keep every workers' comp record: claim decisions, payments, and any notice that benefits are used up.
- Answer VA's Form 10-7959D accurately if you get it.
- Keep itemized medical bills.
- If benefits run out or don't apply, document it and send CHAMPVA the claim with that proof.
For injuries that aren't work-related but involve someone else's fault, see CHAMPVA after an accident.