New reason for wellness programs: Weight-loss surgeries get covered by comp
September 15, 2009 by Christian SchappelPosted in: Health care, Pay and benefits, Special Report - Benefits
More evidence that it pays to emphasize weight loss in your wellness programs:
In two separate cases, courts ruled that workers’ comp must cover weight-loss surgery.
Surgery to ease back pain
The first case involved Adam Childers. While working at Boston’s Gourmet Pizza in Indiana, Childers was struck by a freezer door, injuring his lower back. At the time, Childers weighed 340 pounds.
Doctors said Childers needed surgery to ease his back pain, but that the operation would do him no good unless he first had surgery to reduce his weight, which had ballooned to 380 pounds after the accident.
Childers’ employer agreed to pay for the back surgery, and later a workers’ comp panel said it’d also have to pay $20,000 to $25,000 for his weight-loss surgery (plus disability payments while he was unable to work). His employer appealed, arguing that Childers suffered from a pre-existing health condition — morbid obesity.
However, the court said the restaurant couldn’t prove that Childers’ weight had been a medical problem before the accident. Case closed, he gets the surgery paid for by comp.
Surgery to help arthritic knee
In the second case, Edward Sprague injured his knee in 1976 while working as a mechanic. He then reinjured it in 1999 while working at United States Bakery in Oregon.
During those 23 years, Sprague’s weight climbed from 225 to 350 pounds.
Doctors told Sprague his weight would prevent successful treatment of his arthritic knee condition, so he sought workers’ comp benefits for weight-loss surgery.
A state court ruled Sprague’s bypass surgery should be covered by workers’ comp because the operation was necessary to treat an on-the-job injury.
What can you do?
Most people gain weight as they age — and studies show that heavier employees are at much greater risk for on-the-job injuries.
That’s why companies of all stripes have found wellness programs to more than pay for themselves by preventing injuries and other medical claims.
Group weight-loss initiatives help by making the process fun and competitive. So does replacing high-calorie snacks in vending machines with healthier — but popular — choices.
Tags: boston, bypass surgery, disability, gastric surgery, Gourmet Pizza, Indiana, morbid obesity, Oregon, United States Bakery, wellness programs, workers comp
September 17th, 2009 at 9:21 am
What a crock. This is why comp rates are so high. In both of these cases, the obesity was pre-existing and had nothing to do with the on-the-job injury. Comp should have paid for the surgeries for the injury, not the obesity.
September 17th, 2009 at 10:05 am
Lorie – I understand your feeling however comp law in most states requires that remedies bring the employee to a condition equal to or better than they were at the time of injury. If there is no way for an injured worker to reach an end of healing due to a pre-existing condition – there is no way for the insurer to close the claim, thus incurring added costs for both the employer and the insurer. Additionally, providing the surgery reduces the risk of an employee having the opportunity to reopen the case in the future, thus preventing subrogation lawsuits. We all know when courtrooms are involved – the price-tag goes up!
Another thought are the potential mental health ramifications on an injured worker. Issues like post traumatic stress disorder and depression are at an all time high. Those illnesses are very difficult to disprove and more and more workers are jumping on that band wagon in an effort to attain larger pay-outs and more time off.
In my opinion everyone is at a financial advantage if an injury is treated immediately and properly the first time, even if it means bringing a worker to a quality of health greater than he or she was at, at time of injury. Theoretically, the employees work performance would increase, this creating an unexpected ROI for the employer.
September 17th, 2009 at 10:46 am
Common sense is not a part of the WC system. It is a make-believe world where all calls go in favor of the employee and we all pay the price.
This is why the WC system is so expensive!
September 17th, 2009 at 12:17 pm
Although you are correct HJD in your arguments, it is the accountability factor that I believe Lorie is bringing up. Neither worker’s comp or the employer should be obligated to pay for the weight loss surgery, it should be the employee’s bill. ‘Nuff said.
September 17th, 2009 at 12:52 pm
I think this will only cause further discrimination for overweight people – employers will begin not hiring the applicants who appear to need gastric by-pass surgery!
September 17th, 2009 at 12:57 pm
I can see where this is leading. Discrimination charges against the obese when they are not hired for a job. Or Government mandate that you have to hire overweight people whether you want to or not.
September 17th, 2009 at 1:19 pm
I would think the employer would be eligible for a percentage of handicap reimbursement in this case as any other pre-existing situation the employee may suffer from on the DOI that causes an individual recovering from a work related injury a slower or more difficult recovery due to that pre-existing situation causing higher claim costs. This may differ from State to State however.
September 17th, 2009 at 1:21 pm
Within my organization, we have been going through the Wellness debate and the bottom line with Wellness is that you can provide as much information, guidance and programming for employees, however, unless people are ready and willing to make that change in lifestyle, everything is falling on deaf ears. We have had a program for a few years and the employee buy in is just not there.
WC is meant for on the job injuries, obesity typically doesn’t happen immediately, nor is it job related.
September 17th, 2009 at 2:12 pm
HJD – you make some valid points although some make me even more uncomfortable with this, lol. In particular, the mental health issue. I can see it now. If the EE, rather than comp, had to pay for the gastric surgery, it would never happen. Then you’d have the EE doing the “oh, woe is me, my back is killing me, I’m too fat for surgery, no one will help me, I’m so depressed”, etc., etc. Good Lord!
I also doubt the employer would get any ROI either. Once the EE has lost weight, had surgery and feels like a million bucks, he’ll be out the door to greener pastures with a smile on his face knowing he pulled a fast one and life is good, lol.
I know I sound uncaring and crass, but I’m having one of those days where I have run out of patience with so many people trying to milk the system. No one takes responsibility for their own actions or health anymore. It’s infuriating.
September 17th, 2009 at 2:26 pm
To HRisCOOL,
I agree on principal but we must think of it from this perspective – had the employee not been injured at work he or she would not need the surgery. Perhaps that individual would WANT it – but not there is a legitimate medical need. Make sense?
In truth it would be no different if the man had been hit with the cooler door a the grocery store while shopping – the store’s liability or property casualty insurance would cover it. Wrong place wrong time – maybe…but the law is the law. I think everyone is getting too carried away suggesting that employers will discriminate against overweight people now…as if this one example of WC would create a bee’s nest of activity! Overweight people have been discriminated against for years! Just like tattooed, ugly, too tall, too short, too thin, bald, hairy…etc…it is a fact of life and one that will not go away. Not Ever.
September 17th, 2009 at 2:30 pm
Lorie,
I feel your pain! I know exactly what you are saying! Poor me, Poor me, Poor me, right.
No really, WHAT ABOUT POOR ME?
Perhaps I should claim hostile work environment? LOL…this too shall pass.
Thanks for the feedback!
September 17th, 2009 at 2:49 pm
While I’m on my soapbox…. comp was designed to support and help workers injured on the job through no fault of their own while they recover from their injuries. Yet so many claimants try to turn it into a financial windfall, to be set for life. Social Security was designed to SUPPLEMENT peoples’ retirement income, to help provide basic food and shelter. Yet you always hear “I can’t live on Social Security” like the government should be paying them enough to live in the lap of luxury in retirement. Unemployment and Welfare were designed to help people TEMPORARILY to get through bad times. Yet we have generation after generation of people who have NEVER held a job and have raised entire families on the government dole. And of course, the more kids they have, the more money they get.
When I was a kid, my Dad fell while working on a roof and broke both arms. He was out of work for a couple months. We had to get food stamps and us kids got “reduced” price lunch at school. He was so embarrassed that he couldn’t provide for his family and had to take handouts, he made my mother shop out of town for groceries until he could go back to work. Nowadays, people brag about how much “free” money they get or how they are livin’ large off the public dole. Greed and laziness have spread through our society like a virus. When comp boards and juries allow for unreasonably large payouts it just encourages more of the same. Am I the only one who feels this way?
September 17th, 2009 at 2:53 pm
Well said Lorie!
September 17th, 2009 at 3:31 pm
In this day and age, if there is a medical necessity, most health insurance plans cover WLS. So, it should be recommended to the injured employee to get the surgery under their regular insurance so that the corrective treatment for their OJI will be more successful. If they choose not to do it, it should be documented so that it can’t be used as a reason to re-open or keep open a claim.
September 17th, 2009 at 3:51 pm
Are you kidding me! Mr. Childers was already overweight when the freezer door hit him. It says he only gained 40 pounds more since the injury. So I don’t understand how the restaurant wasn’t able to prove he wasn’t obese before the injury. The weight surgery should have not been covered by W/C but by his regular health insurance. And then just the back surgery by worker’s comp.
Regarding, Mr. Sprague, why didn’t he meet with his doctors sooner to help control his weight gain before it got to point of him needy wait-loss surgery – again that should have been covered by his regular insurance, not w/c.
What about personal accountability? These individuals clearly have none and the rest of their coworkers/companies are paying for it.
September 17th, 2009 at 3:56 pm
Why can’t the W/C Ins company subrogate to the employee’s health insurance carrier?
September 17th, 2009 at 4:11 pm
We’ve become a ‘beggar’ society and it makes me sick. “Give me this!” “Give me that!”, “I deserve this because I’m oppressed!” Kiss my a$$. Go out and work for a living. Stop complaining, break a sweat and EARN SOMETHING!
September 17th, 2009 at 4:13 pm
Sorry about that. Back on topic…There are innumerable complications with weight loss surgery. What happens if he decides to start eating like a pig again? It could easily be a neverending cycle that the employer ends up paying for years and years down the road.
Terrible decision.
September 17th, 2009 at 4:34 pm
HJD – Attitude’s like yours are part of the problem. Insurance is getting more expensive because there are more and more cases like this one. Accountability on all levels is needed; not expectations that someone else should have to pay for all your problems.
September 18th, 2009 at 7:22 am
Lorie, I sooo agree with you! There is less and less personal accountabilty. I am so incredibly sick of it. Has anyone heard of pride? I wouldn’t want something for nothing…
September 18th, 2009 at 7:36 am
OK, getting a little off topic here, but the comment from Gavinz_dad Says in part: “Give me this!” “Give me that!”, “I deserve this because I’m oppressed!” … Go out and work for a living. Stop complaining, break a sweat and EARN SOMETHING!”
I have a picture here on my bulletin board of a white guy with big messy afro styled hair, sporting a scraggly goatee and wearing love beads. The caption says, “GET TO WORK, you aren’t being paid to believe in the power of your dreams.”
I love it and thought you all might too.
September 18th, 2009 at 3:01 pm
I have to wonder if the additional weight gain for each of these guys played into the WC awards. Maybe they claimed they couldn’t participate in activities or have the same level of mobility they had before their accidents. Therefore, the weight gains. Doesn’t make it right. Mr. Childers was already into morbid obesity. I don’t think any insurance company should have paid for the weight loss surgery, not WC or health. I think they should have gone on a weight loss program with a goal, at their own expense, prior to the surgery. What’s wrong with that?
September 18th, 2009 at 5:30 pm
Well said Lorie. I agree Mary – nobody “needs” weight loss surgery. What they “need” is to take better care of their health and themselves. He did not gain weight “because” of the injury. He gained weight because he was eating the wrong foods in the wrong amounts! A person does not just magically become obese, injured or not.
WLS is not the end all be all answer. There are so many complications (physical and mental) and stats on people who actually stay slim afterward is quite low. I agree with Mary, he should have had to go through a weight loss program with specific goals. Put off the surgery until he has achieved that goal. It’s not rocket science. Ah, an ideal world…..we can all dream, can’t we?
September 22nd, 2009 at 11:50 am
HR in IL,
I think you misunderstood my point. My comments were based on the law, not my personal opinion. I think Lorie is right on the money. I live in the mid-west. I have 3 kids one in college, one in middle school and one in kindergarten. My husband worked in the commercial construction industry for 15 years before losing his job a year ago. Luckily he was able to find another quickly…however it came with a cut in pay nearly 1/4 of his average annual earnings. I am Director of Operations for a family owned and operated custom manufacturing facility. My father owns a small retail business that he built with his father, in a highly competitive market. We are hard working, middle class Americans. That is where my perspective comes from.
The bottom line is that I do not believe anyone deserves a free ride and I feel America has seriously crippled itself by protecting unmotivated people that do not want to work. People who suffer from the entitlement syndrome are hurting us all.
That being said – remember those workers in need of the weight loss surgery were hurt at work. That shows me that they are not unmotivated. They were working. Would it be different if the person had a pre-existing condition other being over-weight? Probably, because society assumes fat people are lazy. This is often not the case.
We have all seen firsthand how operating expenses and overhead costs hurt employees. The more we pay as employers the less disposable income there is to spread into other employee benefit areas. My point was that useless litigation makes WC rates rise. Catastrauphic claims follow an employer for 4 years! We as a mid size business cannot continue to sustain increases of gross proportions year after year.
On principal should we have to “foot the bill” for all we are forced to? Both as employers and taxpaying Americans, the answer is emphatically NO! Am I angry that I pay outrageous premiums for every type of insurance coverage under the sun? Yes! Am I frustrated that the current administration is doling out my hard earned tax dollars at a rate of 3 times the rate the country is paying in? Yes! Am I irate that I will contribute to social security my entire working career but probably never have the opportunity to subsidize my retirement with that benefit? Yes, I am. Am I scared that my children will have to work until they die because the stock market is bad, insurance is unattainable and that the government will probably have them paying for the SS deficit? Yes.
So – in response to your comment: I am NOT part of the problem. I do not have the ”stand in line with my hand out” mentality. I choose to have a proactive approach rather than a reactive approach. I do not want to sit and trade insults, however my view is that anyone who dares pass judgment be well versed on all contributing factors in a situation, something I feel you, are not.
September 25th, 2009 at 9:50 am
What would this employee have done if gastric bypass weren’t an option as some people are not good rsiks for it. The doc would have put him on a weight loss program, rehab and exercise. I think that gastric bypass is getting to be the easy way out for obese people who have no self control to eat healthy or exercise. I have a metabolism issue but I compensate by watching what I eat and being active. Enough excuses. Fat people, stand up and get moving and close your mouths after you have eaten a healthy portion!
October 8th, 2009 at 8:10 am
Well said HJD!
As someone who has devoted the past 12 years of my career in senior HR roles, it is very disappointing and sad that the only rational and informed argument in this forum is being made by a Director of Operations and not one from the “HR” experts and “pros” in this forum.
I’m not sure what to make of that. HR wants to sit at the big corporate boardroom table, at the strategic level. Can the HR pros in this forum match up with the well informed, professional, rational Director of Operations and bring the same abilities to the corporate boardroom? Doesn’t look that way … Too bad.
October 8th, 2009 at 9:02 am
Thank you stars! I was rather frustrated with the comments above…noting that the big picture had CLEARLY ben missed by the majority. Your support is appreciated…as I was beginning to think I was missing the big picture.
October 19th, 2009 at 2:29 pm
Lorie: “While I’m on my soapbox…. comp was designed to support and help workers injured on the job through no fault of their own while they recover from their injuries.”
Just one correction here … it doesn’t matter whether the employee is at fault or not, as long as they are not provably intoxicated or engaging in criminal misconduct … the employer pays. Recourse? Discipline according to company policy for violation of plant rules.
October 19th, 2009 at 3:48 pm
I read this one before, but what a crock of manure! I am 58 years old, had a stroke seven years ago, and the only one I have to blame is myself. I was the one putting the food going down the pie hole all the time. I smokeD too AND DON’T ANYMORE.
It just goes to show you that the attorneys, the court, and the American people have totally lost it when it comes down to common sense.
WHEN IN GOD’S NAME ARE PEOPLE GOING TO TAKE RESPONSIBLITY FOR THE SHAPE OF THEIR BODY, THEIR PHYSICAL CONDITION, AND WHAT GOES ON IN OUR COUNTRY. THIS IS NOT An OBAMA OR BUSH THING, IT IS A HORSE MANURE THING!
Again, I am a 58 year old guy who has had one stroke, recovered, am diabetic, who gets off his lard butt and on the exercise equipment about 4-5 times a week and does not want workers compensation or anything. Why don’t we get the people a hankie and we can all feel sorry everybody and have a good cry.
Oh I use to smoke like all get out. I loved the fat food. The doctor told me I would die if I did not quit smoking and start eating right. I could have said, oh smoking did that. My employer made me eat because of my nerves. Instead, I quit smoking, started eating right, and work every day on keeping my diet, excercise, and blood sugar right.
ALL OF THIS POOR THING STUFF JUST MAKES ME MAD. I guess working where I am made me older too.
THERE IS NOTHING BETTER THAN A BUNCH OF LAWYERS THAT ENABLE PEOPLE
IF YOUR OVERWEIGHT, GET HELP, QUIT WHINNING ,AND G,ET INTO THE EXERCISE, REHAB, MAKING EXCUSES, FEELING SORRY FOR YOUR SELF WILL JUST GET YOU AN EARLIER PLACE IN THE CEMETRY. SEE YA!
October 19th, 2009 at 4:48 pm
I have been paying social security since 1969. For most of you that figures out to be forty years. Your darn right I expect the government to pay up on my social security when I am due social security payment. I also suspect to pony up with savings to live in this world.
Of course there are people out there in the world that want to set on their lard butts. They remind me alot of the people that crowd in front when the freeway gets blocked.
See ya
October 20th, 2009 at 7:12 am
Why is it we only see things from our management personal point of view. Be a lawyer and the employee. Lawyers see this as money in their pockets after an award and the employee sees this as a deserved award based that their injury is insured. Now in this day and age when companies NET millions and are cutting back employees you make this an issue of survival for the employee. The fact that employees feel unappreciated, not part of the company and have no stake is where we err. Unemployment was higher in the 70’s and we sat in odd/even lines for fuel but as a 10 year old I went to company picnics, went to work with uncles(notice I said no aunts they were home). We are quick to blame the employee but take a hard look at how our country evolved in 35 years and yes, we created our own issues. Unions protected the stake of the employee from management and each made concessions, we broke the Unions and now there is no middle class, we pay healthcare, and companies make $$ for the stockholders or top 10% of nation, thus workers see the workers comp issue as survival and deserved award. HR must evolve and stop blaming everyone else. Especially when most HR are puppets not an actual resource.
October 20th, 2009 at 7:53 am
HJD — I heartedly agree with your perspective on this issue, which I think nearly everyone else missed as they jumped on “the irresponsible fat guy”. I work in HR, and am keenly aware of the cost associated with WC claims. In this case (as with many claims), it comes down to “pay now or pay more later”. Sounds simplistic perhaps but real nonetheless.
I might add that I am quite surprised by the number of extremely negative comments about overweight people that are posted here, assuming most of these are HR folk. Tells me a lot about the stereotypes and prejudices that are still so prevalent within our ranks and the society as a whole. Yet we want to talk about why certain people don’t get off their “lard butts” and get a job — Go Figure!
October 20th, 2009 at 9:34 am
The whole issue is totally ridiculous. As soon as an employer pays for weight loss surgery and something goes array to whom do we think will get stuck with that liability? As if we don’t know. The system is completely abused. What more does anyone expect these days from a government run entity?