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NC Supreme Court Sets Direct Connection Test for Workplace Injuries

    Client Alerts
  • March 29, 2024

In most situations, medical treatment for workplace injuries is fairly straightforward. Workers' compensation statutes require coverage for procedures necessary to treat and correct injuries or illnesses that occurred at the workplace. What happens, however, when the connection between the injury and the requested treatment appears more tenuous? This week, the North Carolina Supreme Court established a "directly related" test for determining liability for medical procedures that appear separate from the injury.

In Kluttz-Ellison v. Noah’s Playloft Preschool, the plaintiff injured her knee at work. She needed surgery on the knee, but her doctor refused to perform the surgery unless she lost weight. She filed a claim with the compensation carrier for coverage of bariatric surgery intended to assist with the weight loss and allow her to obtain surgery on her knee. The carrier denied the claim on the basis that the weight loss surgery was not related to her workplace injury. The North Carolina Court of Appeals disagreed, concluding that the surgery was sufficiently connected to the injury to require coverage.

In a 5-2 decision, the North Carolina Supreme Court reversed this decision, finding that the lower court did not use the appropriate legal standard for answering this question. The court said that there must be a strong connection between the medical treatment and initial injury to require coverage. In this case, if the bariatric surgery would improve the plaintiff’s overall health, it is outside the scope of workers' compensation liability. The plaintiff’s weight issues were neither caused by nor aggravated by the knee injury. The dissenting justices said that a bright line test would inevitably result in denial of coverage in scenarios not contemplated by this decision.

The Supreme Court remanded the case to the North Carolina Industrial Commission to determine if the bariatric surgery is covered using this directly related test. This decision will likely make it more difficult for employees to obtain coverage for medical conditions typically covered under health insurance as opposed to workers' compensation insurance.

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