February 8, 2008

Asymmetry in Workers Comp

In conventional medicine, breast implants come in pairs: in most circumstances, you install (or replace) both at the same time. There is a compelling aesthetic symmetry in the process. In the idiosyncratic world of comp, however, symmetry is trumped by the "work-related" standard.

Penny Rumple Richardson was injured in an on-the-job car accident. Her breast implants were damaged. The North Carolina Industrial Commission determined that the damage was work-related and approved replacement of both implants. The insurance company appealed. Ms. Richardson's doctor, Greensboro plastic surgeon Dr. David Bowers, originally testified that the right implant had ruptured in the accident and the left implant showed signs of rippling, so he replaced both. But presumably when pressed by defense counsel, he conceded that the left implant most likely had rippling because it was under-filled. In other words, damage to one implant is clearly related to the accident, but damage to the other is not.

At the appeals court level, Judges Barbara Jackson and Sanford Steelman Jr. agreed that breast implants are covered in workers' compensation claims, because they are a "prosthetic device that functions as part of the body." However, they determined that only one implant was damaged as a result of the accident. They sided with the carrier in denying coverage for the "rippled" implant.

Judge James Wynn, Jr. dissented. He pointed out that Richardson needed both implants replaced to ensure that they were "symmetrical and evenly matched." Judge Wynn sought to expand comp coverage to include the rather obvious aesthetic considerations, but he failed to convince his colleagues on the bench.

The Draconian remedy, of course, would be to remove the uncompensable implant. Fortunately, that won't happen.
The case has been sent back to the workers comp commission for resolution. We hope Ms. Richardson has conventional health insurance and that it will cover half of Dr. Bowers's fee. If that doesn't work, Richardson herself will have to pay the price for maintaining essential symmetry.



I can see both sides...

adjusters can be such boobs.

We would not want Penny Rumple Richardson to ripple!!!

I don't see this as humorous. It is the comp. carriers way of minimizing exposure.

Currently I am working with a gentleman who needs multi level back surgery. The comp. carrier has decided it only thinks it has to take responsibility for one level, claiming the other levels are due to DJD. The surgeon says this is ludicrous. The carrier is saying the worker should use his own health insurance, currently COBRA, to pay for the additional levels. When it comes time for PT, will comp. pay for 25% of each session and the health insurer the rest?

Down the road, if another level needs surgical intervention because of the stress of the fusion, the comp. carrier will say they have paid for their level. Yet another surgery will be the result of the surgery at that and the other levels. You cannot parse out the levels of the back.

This is comp's way of delaying care to the worker, who under union contract now has less than a year to try to return to work. And only 2 years of COBRA, which he is having difficulty paying.

Comp. is supposed to help return the injured worker to work; such is not the case, of course. The system needs to be exposed for what it is.

I have to disagree with the unnamed commentator who said "Comp is supposed to help return the injured worker to work... " That is NOT its mission. Its mission is to pay for the medical services required, and loss of income sustained, because of the on-the-job injury and only the on-the-job injury. If getting the worker back to work reduces those costs, good, help the worker get back to work; but that's a means, not an end of the WC system.

Adjusters are not doctors. Adjusters ask the doctors for their opinion on medical questions. In the fact scenario above the injured worker's DR did not state that it is the result of the injury. The benefits are defined by statute and the adjuster must follow the law.


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This page contains a single entry by Jon Coppelman published on February 8, 2008 10:14 AM.

Health Wonk Review and news roundup was the previous entry in this blog.

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