Weight-Loss Surgery Covered by Workers’ Comp, Carolina Appeals Court Finds

Weight-Loss Surgery Covered by Workers’ Comp, Carolina Appeals Court Finds

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Workers’ compensation insurer Erie Insurance Group must pay for weight-loss surgery for an obese woman who was injured at her child-care center, the North Carolina Court of Appeals decided this week.

The appeals court upheld the North Carolina Industrial Commission’s 2021 award of benefits to Robin Kluttz-Ellison, owner of Noah’s Playloft, a preschool in Salisbury. After the woman fell twice and injured her knees, doctors testified that she needed knee surgery. But before she could have the surgery, Kluttz-Ellison needed to lose a considerable amount of weight, her doctors said.

After multiple, unsuccessful attempts to lose weight, the woman and her physicians said that gastric bypass surgery was her only option, and the full Industrial Commission agreed. Erie Insurance appealed, arguing that the obesity was a pre-existing condition and that bariatric surgery was not directly related to the claimant’s compensable injury.

The Court of Appeals ruled against the insurer.

Jackson

“By connecting the dots, we can conclude that but for plaintiff’s need to have right knee surgery to treat her compensable injury, she would not have needed to undergo bariatric surgery,” Judge Darren Jackson wrote for the court. “Therefore, while the existence of Plaintiff’s weight problem was not directly related to the 5 August 2013 accident, the need for bariatric surgery is directly related.”

Gastric bypass surgery, in which the stomach is divided and part of it re-routed, can cost $15,000 to $35,000, according to Obesity Coverage, a medical news website. The North Carolina Workers’ Compensation 2022 medical fee schedule allows up to $3,528 for the procedure.

The case was somewhat unusual due to fact that Kluttz-Ellison was her own employer. She was owner of the day care center and her claim was against her company and her insurance carrier. She also had undergone full-knee replacement in 2010, then suffered an injury to both knees in 2013 when she fell from a ladder while changing a light bulb at the school, aggravating her knee implant, the court recounted.

Then she filed other claims after she tripped over a child’s sleeping cot in 2015.

The judges found that making the bariatric surgery a compensable, necessary treatment was in keeping with the state’s workers’ compensation statutes.

“This result aligns with the spirit of N.C. Gen. Statute 97-25: ‘The rule of causal relation is the very sheet anchor of the Workers’ Compensation Act,’” the court wrote, citing from a 1951 state court ruling that emphasized that the Act should compensate for industrial accidents and should not provide general health insurance benefits.

Based on the testimony of the physicians, “the only way for plaintiff to lose the weight needed to undergo right knee surgery was to undergo bariatric surgery first,” the judge wrote. “Thus, an award for bariatric surgery is not branching out into the field of general health insurance benefits.”

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