Safety and OSHA News

Should comp pay for hip replacement when there was pre-existing condition?

A worker slipped on ice at work and fractured his hip. However, he already had degenerative joint disease, and his replacement surgery had been recommended before his fall. Should workers’ comp pay for the surgery?

Ray Hopson worked for Estenson Logistics in Oklahoma, loading, unloading and driving trucks.

He walked independently but with a small limp, and performed his work duties satisfactorily.

Doctors had told him he needed hip replacement surgery, but he delayed the surgery as long as he could keep working.

Then, one day in February 2014, he slipped on ice inside a truck and fractured his hip in several places.

An orthopedist who examined Hopson said before the fall he had necrosis of the left hip, but that there was likely “some degree of exacerbation that happened with the fall.” The doctor told Hopson to get total hip replacement.

Estenson’s evaluating doctor’s opinion was that Hopson had no permanent effects from his fall.

But Hopson’s evaluating doctor said he had “acute traumatic injury to the left hip.” The doctor noted that before his fall, Hopson was asymptomatic and able to work without restrictions. After the fall, he wasn’t able to bear weight on the hip without substantial pain.

Estenson denied coverage for hip replacement surgery under its workers’ comp policy.

An administrative law judge heard the case and concluded there was significant aggravation of Hopson’s pre-existing condition due to his fall at work and that workers’ comp should pay for his medical care, including surgery, and for temporary total disability compensation.

Estenson appealed to the Workers’ Compensation Commission which affirmed the ALJ’s opinion. The company sought a reversal of the opinion in a state appeals court.

Did pre-existing condition preclude coverage?

Estenson presented two arguments. First, an injury that is compensable under workers’ comp doesn’t include “any pre-existing condition except when the treating physician clearly confirms an identifiable and significant aggravation incurred in the course and scope of employment.”

This part of Oklahoma’s comp law puts the burden on the injured worker to show that an at-work incident caused identifiable and significant aggravation of the pre-existing injury for it to be compensable.

The court noted that Hopson’s emergency room records show he fractured his left hip in multiple places and his treating doctor said there was “some degree of exacerbation that happened with the fall.”

That was good enough for the court to reject Estenson’s first argument.

The company also contended that an award to cover surgery under workers’ comp was contrary to state law in this case. Estenson argued the total hip replacement can’t be connected to Hopson’s employment if it was recommended before the work injury and was connected to his pre-existing condition.

Again, the court rejected the company’s argument. It said there wasn’t anything in Oklahoma’s law that said post-injury treatment isn’t connected to the injury if it was recommended before the injury.

“The record contains evidence that hip replacement surgery was reasonably necessary to repair the fracture of the left femoral head,” the court wrote in its opinion. Therefore it upheld the order for workers’ comp to cover Hopson’s surgery and for him to receive temporary total disability compensation.

What do you think about the decision in this case? Let us know in the comments.

(Estenson Logistics v. Ray Vinson Hopson, Court of Civil Appeals of the State of Oklahoma, Division I, No. 113572, 9/24/15)

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Comments

  1. It looks to me that the court got this one right.
    There is something I would recommend to anyone who has an employee with a pre-existing medical condition. As soon as the company knows about an existing illness, such as this, the employee should be examined by a physician with a list of their job duties and found to be medically capable of performing their job safely. If this man walked around with a limp then surely his supervisors had to be aware of it. It should have been clear to anyone that should this employee fall, the resulting injury would be a lot more serious than someone with a healthy hip joint. By ignoring the medical situation they now own it and have to cover the cost of the surgery.

Trackbacks

  1. […] Safety News Alert reported on a recent case in which an employee had a diagnosed medical condition, but suffered a work injury that caused the condition to become much worse. The employee was ultimately able to get benefits for his injury, but had to turn to the Workers’ Compensation Commission for help after the benefits claim was initially denied. The employer’s insurer also put the worker through multiple stages of appeal before the state court finally upheld the grant of benefits to the worker. […]

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