SAIF Corp. v. Sprague

190 P.3d 443, 221 Or. App. 413, 2008 Ore. App. LEXIS 1102
CourtCourt of Appeals of Oregon
DecidedJuly 30, 2008
Docket00-07404, 01-01561; A133701
StatusPublished
Cited by4 cases

This text of 190 P.3d 443 (SAIF Corp. v. Sprague) is published on Counsel Stack Legal Research, covering Court of Appeals of Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
SAIF Corp. v. Sprague, 190 P.3d 443, 221 Or. App. 413, 2008 Ore. App. LEXIS 1102 (Or. Ct. App. 2008).

Opinions

[415]*415EDMONDS, P. J.

Jerry’s Specialized Sales (employer) and its insurer, SAIF, seek judicial review after the Workers’ Compensation Board allowed claimant’s claim for medical services under ORS 656.245(1) following our remand to the board for reconsideration. Sprague v. United States Bakery, 199 Or App 435, 112 P3d 363, modified on recons, 200 Or App 569, 116 P3d 251 (2005), rev den, 340 Or 157 (2006). On review, we affirm.

This case is about the compensability of medical expenses and whether the first sentence or the second sentence of ORS 656.245(l)(a) applies to claimant’s circumstances where the board found that his obesity condition required gastric surgery in order that claimant could lose weight so that his knee condition could be treated successfully by a knee replacement procedure. The statute provides,

“For every compensable injury, the insurer or the self-insured employer shall cause to be provided medical services for conditions caused in material part by the injury for such period as the nature of the injury or the process of the recovery requires, subject to the limitations in ORS 656.225, including such medical services as may be required after a determination of permanent disability. In addition, for consequential and combined conditions described in ORS 656.005(7), the insurer or the self-insured employer shall cause to be provided only those medical services directed to medical conditions caused in major part by the injury.”

The essential facts in this case are not controverted. Claimant compensably injured his left knee in 1976 while working for SAIF’s insured. He weighed 225 pounds at the time of the injury. Claimant began gaining weight after his 1976 injury. By January 1996, he weighed 320 pounds, and his physicians were considering a surgical approach to bring his weight under control. In 1998, his left knee became symptomatic once again. In February 1999, claimant suffered a second injury to his knee while working for United States Bakery. That employer accepted claimant’s new injury as compensable. In December 2000, SAIF issued a modified acceptance, noting that in addition to its previous acceptance [416]*416of claimant’s 1976 knee injury, it was also accepting “arthritis of the lateral compartment, left knee.” In 2001, when claimant weighed 350 pounds, gastric bypass surgery was performed.

Claimant filed a workers’ compensation claim for the medical expenses incurred as a result of the surgery. He contended before the board that the surgical expenses were compensable because his current knee condition could not be treated successfully without claimant losing 100 to 150 pounds. In claimant’s view, it was necessary to first treat his morbid obesity as part of the treatment of his knee condition. SAIF countered that the claim for medical services for the gastric bypass surgery was not compensable because claimant’s obesity was not caused by the 1976 knee injury.

As we observed in our initial opinion, the board, in deciding the claim, found that claimant needed gastric surgery

“partly because he needs knee replacement surgery and he must lose weight for the knee surgery to be successful. However, the gastric surgery was also performed for the obesity.”

199 Or App at 439 (emphases in original). Based on its findings, the board concluded,

“Although claimant has no accepted gastric condition, the bypass surgery was performed in part to treat his left knee condition (which is due largely to the 1976 work injury). Insofar as the surgery was performed to treat claimant’s obesity and his left knee, we find that the claim is best characterized as a claim for medical services for a consequential condition. Therefore, under ORS 656.245(l)(a), claimant must prove that his compensable knee injury was the major contributing cause of his need for gastric surgery. That means that he must establish that his work injury (or injuries) contributed more to his need for gastric surgery than all other causes combined.”

(Footnotes and record citations omitted.)

Claimant sought judicial review in this court, arguing that the board erred by applying the major contributing cause standard in the second sentence of the statute instead [417]*417of the material contributing cause standard in the first sentence of the statute. Claimant’s primary argument on judicial review was that the gastric bypass surgery was compensable as medical treatment for his current knee condition under the first sentence in ORS 656.245(l)(a). SAIF responded that, because claimant’s current knee condition was a consequential condition, the board correctly decided the compensability of the gastric surgery under the second sentence in the statute. Consequently, based on how the parties had framed the issue, the threshold issue on judicial review was whether the gastric surgery expenses were compensable under the first sentence of the statute to treat a condition that had been caused in material part by a “compensable injury” or whether the board had correctly ruled that the second sentence of the statute governed claimant’s claim.

The parties’ arguments required us to discern the intent of the legislature regarding the meaning of the two sentences in ORS 656.245(l)(a) as applied to the circumstances of claimant’s claim. We disagreed with the board’s reasoning that the claim was “best characterized as a claim for medical services for a consequential condition.” As we perceived the issue, it was whether the treatment of a noncompensable condition during the course of treatment for a compensable condition is compensable. We explained, “The statutory definition of a ‘consequential condition’ is not satisfied, as the board reasoned, simply because the gastric bypass surgery was performed, in part, to treat claimant’s obesity and, in part, to treat his knee condition.” 199 Or App at 440. We also observed that “it could be that the treatment of claimant’s obesity, a noncompensable condition, is a necessary prelude to the treatment of his compensable knee condition.” Id. We concluded,

“The evidence underlying this claim is that the 1976 knee injury and the development of arthritis in that knee constitute an accepted combined condition that now requires total knee replacement surgery. The issue on remand under ORS 6[56].245(l)(a) is whether the gastric bypass is a medical service for a condition that was ‘caused in material part’ by the accepted knee condition.”

Id. at 440-41 (first emphasis in original; second emphasis added).

[418]*418SAIF sought reconsideration of our holding.

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Related

Frazer v. Enterprise Rent-A-Car Co.
374 P.3d 1003 (Court of Appeals of Oregon, 2016)
SAIF Corp. v. Swartz
270 P.3d 335 (Court of Appeals of Oregon, 2011)
SAIF Corp. v. Sprague
217 P.3d 644 (Oregon Supreme Court, 2009)
SAIF Corp. v. Sprague
190 P.3d 443 (Court of Appeals of Oregon, 2008)

Cite This Page — Counsel Stack

Bluebook (online)
190 P.3d 443, 221 Or. App. 413, 2008 Ore. App. LEXIS 1102, Counsel Stack Legal Research, https://law.counselstack.com/opinion/saif-corp-v-sprague-orctapp-2008.