Weight Loss Surgery Compensable Only if Directly Related to Workplace Injury

Takeaway: Workers’ compensation statutes generally provide compensation for reasonably required medical treatment to employees who have had a compensable workplace injury. However, courts are likely to require compensation only for those treatments directly related to the workplace injury.

An employee claiming workers’ compensation may receive compensation for medical treatment only if that treatment—including for weight loss surgery—is directly related to the workplace injury, meaning that the injury either caused, aggravated, or accelerated the condition that requires treatment, the Supreme Court of North Carolina ruled.

An employee at a preschool brought workers’ compensation claims against her employer and its workers’ compensation carrier for injuries sustained in two workplace accidents. The first accident occurred when she fell several feet off a ladder while changing a lightbulb; the second happened when she tripped on a child’s cot and fell.

Prior to the accidents, the employee had a prosthetic secured by hardware placed in her right knee and had been diagnosed with obesity. After the accidents, her doctors determined that she needed additional knee surgery to address loosened hardware in her knee. They also recommended that she undergo bariatric weight loss surgery because they couldn’t safely perform the required knee surgery until her body mass index (BMI) was significantly lowered.

The North Carolina Industrial Commission’s deputy commissioner denied the claim regarding the loosened knee hardware and consequently denied the claim for bariatric surgery because it was based on the compensability of the knee surgery. The employee appealed the decision to the full commission.

Meanwhile, the plaintiff had bariatric surgery and lost weight. The corrective knee surgery was then performed. After she submitted additional evidence to the commission, it concluded that the knee surgery was related to her workplace injuries and was compensable. However, the commission concluded that the “plaintiff failed to establish that weight loss treatment is medically necessary as a result of her compensable injuries” and denied compensation for the bariatric surgery.

The commission later issued an amended opinion, finding that the bariatric surgery “was medically necessary to achieve a BMI of less than 40,” a prerequisite to allowing the plaintiff to undergo the knee surgery, and thus was compensable. The preschool and the insurer appealed the commission's opinion to the North Carolina Court of Appeals.

The North Carolina Court of Appeals examined whether the treatment was “directly related to the original compensable injury” and held that “while the existence of plaintiff’s weight problem was not directly related to the accident, the need for bariatric surgery is directly related” because she could not undergo knee surgery until she lost sufficient weight. The preschool and the insurer asked the North Carolina Supreme Court to grant discretionary review of the appellate court’s decision.

Reviewing the decision, the state Supreme Court formally endorsed the longstanding test developed and consistently applied by the court of appeals. This “directly related” test allows an employee to receive compensation for medical treatment “only if that treatment is directly related to the workplace injury, meaning there is a sufficiently strong causal relationship between the condition that requires treatment and the workplace injury.” The court explained that when examining how one injury, condition, or symptom could be causally related to another, it must be considered whether the former “caused, aggravated or accelerated the latter.”

Noting that these three factors can be articulated as three separate tests, the court said that a causal relationship exists: 1) when the workplace injury caused the condition for which treatment is sought, 2) when the workplace injury materially impacts the condition for which treatment is sought by aggravating that condition or causing new symptoms, or 3) if the condition “was materially accelerated by the workplace injury—meaning the condition did not require medical treatment or intervention of any kind before the workplace injury but now requires treatment to aid in treatment of the workplace injury.”

If any of these criteria are met, the treatment is directly related to the workplace injury and is compensable, the court determined. If not, the treatment is, at most, indirectly related to the workplace injury and is not compensable under the workers’ compensation system. This causal standard ensures that medical compensation will be limited to conditions directly related to the workplace injury and “will not convert our compensation law into a system of compulsory general health insurance.”

The court noted that neither the commission nor the appellate court had properly applied this test. The commission examined only whether the bariatric surgery was medically necessary to achieve the requisite weight loss to undergo the knee surgery and failed to make any findings concerning the causal relationship between the plaintiff's body weight—the “condition”—and the workplace injury. The appellate court focused on the treatment, not the condition, and found “a direct line connecting the dots between plaintiff’s original compensable injury and the commission's award for bariatric surgery,” the court said.

The court reversed the decision and instructed the appeals court to remand the case to the commission for further consideration.

Kluttz-Ellison v. Noah’s Playloft Preschool & Erie Insurance Group, N.C., No. 173PA22 (March 22, 2024).

Rosemarie Lally, J.D., is a freelance legal writer based in Washington, D.C.