September 2, 2009
September 2, 2009
In SAIF Corp. v. Sprague, the Oregon Supreme Court upheld the workers’ compensation claim of an employee who sought coverage for gastric bypass surgery, on the grounds that the surgery was necessary to treat a decades-old on-the-job knee injury. Sprague injured his knee on the job in 1976, filed a workers’ comp claim, and sought treatment. In 1999, he reinjured his knee and filed a new workers’ comp claim with a new employer. He also was successful in expanding his original claim to include a new condition, consequential arthritis in the knee. In 2000, his knee had deteriorated and his doctor recommended a knee replacement. However, plaintiff (who weighed over 300 pounds) needed to lose weight to be eligible for the knee surgery and to relieve pressure on the injured knee. His doctor recommended gastric bypass surgery, but both workers’ comp insurers (for his new and old employers) refused to pay for it. The insurers argued that the gastric bypass was not covered because it was directed at Sprague’s obesity, which had existed before the original 1976 injury.
The Oregon Supreme Court disagreed. The insurers did not dispute that the current knee problems were compensable, because they were related to the original on the job injuries. The only relevant issue was whether the gastric bypass surgery was “directed to” the knee injury. The court ruled that it was, because the medical evidence was undisputed that the weight loss was necessary to the success of the surgery. It was irrelevant that the Sprague would also obtain free surgery that had substantial cosmetic benefits (as Al Roker, John Popper, Roseanne Barr, Star Jones, Randy Jackson, and others can attest).
As World of Work pointed out earlier, this doesn’t mean that all gastric bypasses will now be covered by workers’ comp. However, the statute that mandated this decision just doesn’t strike the balance that the workers’ comp system promised. The system was created as a compromise between employers and employees. Employees received a defined benefit for any on-the-job injury regardless of fault. Employers received protection from high punitive damage awards and the knowledge that their costs would be controlled. While the system often works well, decisions like this show that it doesn’t always. According to some experts, gastric bypass surgery costs between $20,000-and $25,000. That’s a cost that these employers might not have had to pay absent the workers’ comp system.
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