SAIF told to pay for weight-loss surgery
The Oregon Court of Appeals rules an obese man's gastric bypass is covered to treat his knee injured at work
The state Court of Appeals said Wednesday that gastric-bypass surgery could be covered by workers' compensation insurance if the operation is necessary to treat an on-the-job injury.
In a case with roots more than 30 years old, the appellate court ruled, in a largely technical decision, for Edward G. Sprague, who once worked at United States Bakery in Eugene.
His lawyer, Christopher Moore of Eugene, said Wednesday it is unlikely the decision will generate a tide of workers' compensation claims for the weight-loss operation.
"Gastric bypass is very extreme surgery, and you have to be pretty grossly obese to have it," Moore said. "There's a limited number of situations where that kind of treatment is going to benefit another condition."
The insurer in the case is SAIF Corp., the quasi-governmental entity that provides workers' compensation insurance. Chris Davie, vice president for corporate policy and external affairs, said the question of covering gastric-bypass surgery only "comes up from time to time."
SAIF has about a month to decide whether to appeal to the state Supreme Court.
Sprague was not available for comment, but court papers recite his history:
Genetically inclined to obesity, Sprague weighed 225 pounds in March 1976 when he injured his left knee on his job as a mechanic. His employer's workers' compensation insurer, SAIF, paid for the surgery to fix the knee. But the operation left Sprague susceptible to arthritis, which he later developed.
By February 1999, Sprague was working as a baker at United States Bakery, where he reinjured the knee. Doctors said he needed a total knee replacement. But by then, Sprague weighed 320 pounds, and the doctors decided he first needed gastric-bypass surgery to help him lose at least 100 pounds.
Gastric-bypass surgery is a drastic measure and performed only on people who are at least 100 pounds over their ideal weight. The procedure reduces the size of the stomach to limit the body's intake of food and can cost at least $20,000.
Sprague asked for workers' compensation to cover the procedure because without it, he could not get the right treatment for his on-the-job knee injury.
The bakery's workers' compensation insurer -- Gates McDonald -- refused to cover it. Sprague then asked SAIF to pay because his 1999 injury was a consequence of the 1976 injury. SAIF refused.
In 2001, Sprague had the gastric-bypass surgery. Moore said Wednesday that United States Bakery paid for the operation.
The case then went on a litigation merry-go-round. Sprague took SAIF's decision to the Workers' Compensation Board, which in June 2003 agreed with SAIF. The panel said Sprague had to prove that his 1999 injury was the major reason for the gastric-bypass surgery.
Sprague's lawyer, Moore, went to the Court of Appeals, which in 2005 ruled in favor of Sprague. The court said that the Workers' Compensation Board did not apply the right legal standard in making its decision. The court told the board to look at Sprague's case again.
SAIF asked the Court of Appeals to reconsider its decision. The court agreed, but ultimately sent the case back to the board. SAIF appealed to the Oregon Supreme Court, which in 2006 declined to hear it.
The Workers' Compensation Board heard the case again and this time ruled for Sprague. SAIF went back to the Court of Appeals and asked for another review. The court responded Wednesday, with a majority opinion by Judge Walter Edmonds and a concurrence by Judge David Brewer.
"SAIF is incorrect when it argues that the only way in which the gastric surgery expenses could be held to be compensable is if claimant's knee injury caused his obesity condition," the court ruled.
If an operation will treat a condition that was caused by an injury covered by workers' compensation -- in Sprague's case, the arthritis requiring a knee replacement -- then the operation should be covered, too, the court said.
Anne Saker: 503-294-7656; annesaker@news.oregonian.com
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