05/19/2009 04:22:41 PM EST
Thomas A. Robinson on Carrier Payment for Gastric Bypass Surgery "Associated" With Treatment for Knee Injury: Sprague v. SAIF Corp.
On April 23, 2007, Duke University published a study of its own employees, which found that gaining too much weight is not only bad for an employee's waistline; when it comes to the employer or carrier's workers' compensation expenses, it is bad for the employer's bottom line. The Duke University Medical Center analysis found that obese workers filed twice the number of workers' compensation claims, had seven times higher medical costs from those claims, and lost 13 times more days of work from work injury or work illness than did their non-obese fellow workers. The researchers examined the records of 11,728 Duke employees who received health risk appraisals between 1997 and 2004. The analysis covered a diverse group of workers--administrative assistants, groundskeepers, nurses, and professors--and found that the average medical claims costs per 100 employees were $51,019 for the obese and $7,503 for the non-obese [see http://www.dukehealth.org/HealthLibrary/News/10044].
Thomas A. Robinson states that one way in which workers' compensation medical costs can be so significantly increased springs from the fact that often the employer must treat--either directly or indirectly--the non-work-related obesity in order to treat the work-related injury. That scenario was illustrated recently in an Oregon case, Sprague v. SAIF Corp., 2008 Ore. App. LEXIS 1102 (July 30, 2008), in which an employer was required to underwrite the costs of gastric bypass surgery for an obese claimant in order that he could lose sufficient weight that his knee condition--brought about by a work-related injury--could be successfully treated by knee replacement surgery.
Robinson analyzes the case and discusses relevant issues related to the payment of medical expenses only indirectly associated with a compensable injury. He contrasts the general rule requiring the employer to cover all costs associated with the compensable injury--including the treatment of other conditions associated with the claimant's compensable condition, though not associated with the original injury--with the so-called "direct and natural consequence rule," which generally requires an employer to cover the costs of medical treatment for conditions that naturally flow from the original injury. He posits that the Oregon case illustrates that an employer's liability is not limited to payment for the deterioration in a claimant's condition brought about by the compensable injury nor to other medical conditions that result from the injury; it is considerably broader. The employer may generally be required to treat a battery of problems to the extent that they impede the treatment required to alleviate the effects of the compensable injury. That this is true is borne out by the Duke University statistics, Robinson observes. He finally observes that, as employers have taken aggressive steps to reward good behavior, for example, by providing financial incentives and health-related programs to assist workers in smoking cessation efforts, they are now beginning to turn to another significant health problem for American workers: obesity. “It is no wonder why Duke and other large employers have begun to take such an aggressive stance on employee health, in general, and on employee obesity, in particular.”
To read Robinson's additional comments and practice points on this topic, see his expert commentary article.