A case that a North Carolina pre-school owner had won on appeal has since gone under review by the state high court. The high court overturned the appellate court’s decision. Anyone facing workers’ compensation issues associated with medical conditions may want to read more about the woman’s circumstances.
The woman who owns the pre-school had suffered multiple injuries on the job. One such injury was so severe (after falling off a ladder) that medical professionals recommended knee surgery. However, the surgeon told the patient that she must lose weight to be able to undergo the prescribed knee surgery and recommended stomach bypass surgery for weight loss.
2 entities said workers’ compensation should cover the bypass surgery
Both the Industrial Commission and an appellate court ruled that the suggested bypass surgery was compensable. This means that workers’ compensation would cover expenses associated with the procedure. However, in a turn of events, the North Carolina Supreme Court overturned the lower court’s decision, stating that the workers’ compensation system is not a type of health insurance, and the lower court had not applied the proper legal standard in the case.
For a medical procedure to be compensable under workers’ compensation, it must be directly related to a workplace injury. As such, the high court ruled that bypass surgery was not directly related to the knee injury that the woman suffered when she fell off a ladder at work. If a person’s condition or need for surgery was the result, or worsened by, a workplace accident, then it is not compensable.
High court explains its decision
The North Carolina Supreme Court explained that, while the Industrial Commission and appellate court analyzed whether bypass surgery was a medical necessity to achieve weight loss, both bodies had failed to demonstrate a direct link between the bypass surgery as a medical necessity directly related to the fall from the ladder.
Many claims receive denial upon initial filing but later receive approval on appeal. Because workers’ compensation issues are often complex, it is wise to seek legal guidance before filing a claim in connection with a workplace injury. Such benefits can help offset medical bills, replace lost wages and provide additional financial supplements to a recovering worker. However, there are stringent rules in place to determine whether a specific treatment or procedure is compensable.
