IN THE SUPREME COURT OF NORTH CAROLINA

No. 173PA22

Filed 22 March 2024

ROBIN KLUTTZ-ELLISON, Employee

v.

NOAH’S PLAYLOFT PRESCHOOL, Employer, and ERIE INSURANCE GROUP, 

Carrier

On discretionary review pursuant to N.C.G.S. § 7A-31 of a unanimous decision 

of the Court of Appeals, 283 N.C. App. 198 (2022), affirming an opinion and award

entered on 11 March 2021 by the North Carolina Industrial Commission. Heard in 

the Supreme Court on 20 September 2023. 

Shelby, Pethel and Hudson, P.A., by David A. Shelby, for plaintiff-appellee.

Hedrick Gardner Kincheloe & Garofalo LLP, by M. Duane Jones and Lindsay 

N. Wikle, for defendant-appellants. 

DIETZ, Justice.

Under our workers’ compensation statutes, an employee who suffers a

compensable injury in a workplace accident may receive compensation for any

medical treatment that “may reasonably be required to effect a cure or give relief.” 

N.C.G.S. § 97-2(19) (2023); see also id. § 97-25(c). 

Despite this broad language, the Court of Appeals has long held (quite 

understandably) that this provision does not apply to every medical treatment; it 

applies only to those treatments that are “directly related” to the workplace injury.
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Were it otherwise, workers’ compensation would too easily transform into general 

health insurance, forcing employers to cover treatments for medical conditions with 

no connection to the workplace injury.

To assess whether a treatment is directly related, the Court of Appeals 

examines the strength of the “causal relationship” between the condition that 

requires treatment and the workplace injury. See, e.g., Perez v. Am. Airlines/AMR 

Corp., 174 N.C. App. 128, 133 (2005). This approach, which this Court has favorably 

recognized but never formally endorsed, protects the need for causality in assessing

workers’ compensation—a need that is “the very sheet anchor” of the system. Duncan 

v. City of Charlotte, 234 N.C. 86, 91 (1951).

As explained in more detail below, we endorse the test as it has developed in 

the Court of Appeals. Under the “directly related” test, treatment for a medical 

condition is directly related to a workplace injury, and therefore compensable, if there 

is a sufficiently strong causal relationship between the condition that requires 

treatment and the workplace injury. Perez, 174 N.C. App. at 133. This requires a 

showing that the condition for which treatment is sought (1) was caused by the 

workplace injury; (2) was aggravated by the workplace injury; or (3) did not require 

medical treatment or intervention of any kind before the workplace injury but now

requires treatment solely to remedy the workplace injury.

If any of these criteria are met, the treatment is directly related to the 

workplace injury and is compensable. If not, the treatment is, at most, indirectly
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Opinion of the Court

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related to the workplace injury and is not compensable under the workers’ 

compensation system. 

Our holding today is largely a restatement of longstanding Court of Appeals 

precedent. Nevertheless, we find it necessary to reverse the Court of Appeals’ decision 

and remand with instructions to further remand this case to the Industrial 

Commission. As explained in more detail below, neither the Commission nor the 

Court of Appeals properly applied the test set out in this existing line of Court of 

Appeals cases, which we have now formally endorsed. We therefore reverse and 

remand this matter so that the Commission can apply the test set out in this opinion.

Facts and Procedural History

Plaintiff Robin Kluttz-Ellison worked at Noah’s Playloft Preschool. Plaintiff 

brought two workers’ compensation claims against defendants (her employer and 

workers’ compensation carrier) for injuries sustained in two different workplace 

accidents. The first accident occurred when plaintiff fell several feet off a ladder while 

changing a lightbulb. The second incident occurred when plaintiff tripped on a child’s 

sleeping cot and fell.

Defendants denied a number of plaintiff’s claims, asserting that the alleged 

injuries were unrelated to the workplace accidents. The Commission ultimately 

consolidated plaintiff’s claims for a single hearing.

Before these accidents, plaintiff had a medical procedure known as knee 

arthroplasty, which required a prosthetic secured with hardware to be placed in her
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Opinion of the Court

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right knee. In addition, plaintiff had struggled with body weight issues for many 

years. Her medical care providers previously diagnosed her with obesity and

recommended treatments ranging from changes to her diet to prescription weightloss medications.

After the workplace accidents, plaintiff’s care providers determined that she 

needed additional knee surgery to address a loosening of the hardware in her right 

knee. They also recommended that plaintiff undergo a form of bariatric weight loss 

surgery known as gastric bypass. Plaintiff’s care providers believed this weight loss 

surgery was necessary because they could not safely perform the required knee 

surgery until plaintiff’s body mass index was lowered significantly. These care 

providers concluded that bariatric surgery was the only available treatment that 

would lead to a sufficiently rapid loss of body weight.

Following a hearing, the deputy commissioner denied plaintiff’s claim with 

respect to the loosened hardware in her right knee. As a result, the deputy 

commissioner also denied the claim for bariatric weight loss surgery, which was based 

on the compensability of plaintiff’s knee surgery. Plaintiff then appealed the deputy 

commissioner’s decision to the Full Commission.

In the interim, plaintiff successfully underwent bariatric surgery and lost a 

substantial amount of weight. Plaintiff then underwent the corrective surgery on her 

right knee. After the surgeries, plaintiff moved to submit additional evidence to the 

Full Commission to support her claim that her knee hardware loosened because of 
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Opinion of the Court

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the workplace accidents. She also moved for permission to take additional depositions

from her care providers. The Commission granted her motions. 

The Commission later entered an opinion and award concluding that plaintiff’s 

right knee surgery was related to her workplace injuries and was compensable. But 

the Commission concluded that plaintiff “failed to establish that weight loss 

treatment is medically necessary as a result of her compensable injuries” and denied 

compensation for plaintiff’s bariatric surgery.

Two weeks later, plaintiff moved to reconsider the Commission’s opinion and 

award and requested permission to introduce new evidence. The Commission denied 

plaintiff’s request to introduce new evidence but entered an amended opinion and 

award that changed its decision with respect to the bariatric surgery. 

The amended opinion and award found that the bariatric surgery “was 

medically necessary to achieve a BMI of less than 40, a prerequisite to allowing 

Plaintiff to undergo the revision right total knee arthroplasty.” Based on this finding, 

the Commission concluded that the bariatric weight loss surgery was compensable. 

Defendants appealed the Commission’s opinion and award to the Court of 

Appeals, challenging a number of rulings, including the award of compensation for 

the bariatric surgery. See Kluttz-Ellison v. Noah’s Playloft Preschool, 283 N.C. App. 

198 (2022).

With respect to that surgery, the Court of Appeals examined whether the 

treatment was “directly related to the original compensable injury.” Id. at 213. The 
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court held that “while the existence of Plaintiff’s weight problem was not directly 

related to the 5 August 2013 accident, the need for bariatric surgery is directly 

related” because plaintiff could not undergo her knee surgery until she lost sufficient 

body weight. Id. at 214.

We allowed defendants’ petition for discretionary review with respect to this 

portion of the Court of Appeals’ decision. 

Analysis

In our workers’ compensation system, an employee is entitled to compensation 

for injuries “by accident arising out of and in the course of the employment.” N.C.G.S. 

§ 97-2(6) (2023). For many decades, this Court has held that the phrase “arising out 

of employment” imposes a causal element on workers’ compensation claims. See, e.g., 

Taylor v. Town of Wake Forest, 228 N.C. 346, 350 (1947); Allred v. Allred-Gardner, 

Inc., 253 N.C. 554, 557 (1960). Thus, to prove claims for workers’ compensation 

benefits, employees must prove that the workplace accident caused their injuries. 

Sprouse v. Mary B. Turner Trucking Co., 384 N.C. 635, 643 (2023). 

We imposed this causal requirement because the Workers’ Compensation Act 

“was never intended to be a general accident and health insurance policy.” Weaver v. 

Swedish Imps. Maint., Inc., 319 N.C. 243, 253 (1987). “This rule of causal relation is 

the very sheet anchor” of the Act. Duncan, 234 N.C. at 91. “It has kept the Act within 

the limits of its intended scope,—that of providing compensation benefits for 

industrial injuries, rather than branching out into the field of general health 
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insurance benefits.” Id.

When employees meet this causal requirement, and all other elements of their

claim, they are entitled to workers’ compensation. This includes “medical 

compensation,” which is defined as medical or rehabilitative treatment that “may 

reasonably be required to effect a cure or give relief.” N.C.G.S. § 97-2(19); see also id.

§ 97-25(c). 

But here, too, our appellate courts have imposed a causal requirement to 

safeguard the purpose of the workers’ compensation system. This causal test 

originated in a Court of Appeals opinion several decades ago, which held it “[l]ogically 

implicit” that any compensable medical treatment “be directly related to the original 

compensable injury.” Pittman v. Thomas & Howard, 122 N.C. App. 124, 130 (1996).

In Pittman, the employee suffered a compensable back injury at work that 

caused difficulty moving and walking. Id. at 126, 132. The employee underwent 

spinal surgery. Id. at 131. After the surgery, the employee continued to have trouble 

walking and sought additional treatment. Id. The Industrial Commission denied that 

treatment request after finding that the employee’s symptoms stemmed from a 

congenital spine defect that was not “caused by” the workplace injury. Id. at 131–32.

Applying the “directly related” test, the Court of Appeals in Pittman affirmed 

the Industrial Commission’s decision, holding that the Commission’s findings 

supported the “legal conclusion that plaintiff’s current condition was not related to 

the original compensable injury.” Id. at 133 (emphasis added). Importantly, it was 
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Opinion of the Court

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“plaintiff’s current condition,” not the treatment plaintiff sought, that was the focus 

of the analysis. Id. In other words, the Pittman test examines causality between the 

workplace injury and the condition needing treatment. 

Although Pittman did not expressly state why it was necessary to focus on the 

condition to be treated, it flows from the same “logically implicit” rationale that

Pittman relied upon to create the test. Because the “rule of causal relation is the very 

sheet anchor” of workers’ compensation, an award of medical compensation requires 

a showing that the condition being treated is causally tied to the workplace injury.

Duncan, 234 N.C. at 91. 

For example, suppose an employee who is being treated for a preexisting 

condition suffers an unrelated workplace injury. The employee’s care providers might 

recommend changing the course of treatment because a new treatment would help 

the employee recover from the workplace injury more quickly or with less pain. That

treatment would therefore “reasonably be required to effect a cure or give relief” from 

the workplace injury. N.C.G.S. § 97-2(19); see also id. § 97-25(c). 

Although this new treatment concerns a preexisting condition, there are many 

scenarios where the condition nevertheless is causally related to the workplace 

injury. Perhaps that workplace injury aggravated the preexisting condition. Perhaps 

the injury triggered a need for medical treatment or intervention of the condition 

where none existed before. In these circumstances, awarding compensation for the 

treatment is consistent with the causal anchor that grounds our workers’ 
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Opinion of the Court

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compensation system.

By contrast, there are many scenarios where a preexisting condition has no 

causal connection to the workplace injury but that condition’s treatment nevertheless 

is impacted by the workplace injury. Imagine an employee undergoing cancer 

treatment. After a workplace injury, the employee’s care providers might recommend 

changes to that cancer treatment—for example, another round of chemotherapy 

rather than a surgery that would take place too soon after a surgery for the workplace 

injury.

In that circumstance, our workers’ compensation system does not require the 

employer to take over the cancer treatment and pay for the chemotherapy. That 

cancer treatment is part of the employee’s general health care and outside the scope 

of workers’ compensation. 

 Simply put, if there is no causal connection between a workplace injury and 

a preexisting condition, forcing the employer to pay for treatment of that preexisting 

condition makes the employer responsible not for the consequences of a workplace 

accident but for an employee’s general health and well-being. That is not workers’ 

compensation; that is health insurance. Weaver, 319 N.C. at 253.

For this reason, the Court of Appeals has consistently applied the “directly 

related” test by examining whether there is “a causal relationship between the 

medical condition and the work-related injury.” Perez, 174 N.C. App. at 133; see also

Parsons v. Pantry, Inc., 126 N.C. App. 540, 542 (1997); Adams v. Frit Car, Inc., 185 
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N.C. App. 714, 720 (2007); Brewer v. Rent-A-Ctr., 288 N.C. App. 491, 497 (2023), 

vacated on other grounds, No. 139PA23 (N.C. Feb. 2, 2024) (order). By focusing on 

that causal relationship between condition to be treated and workplace injury, the 

Court of Appeals ensured that medical compensation does not undermine the causal 

sheet anchor that grounds the workers’ compensation system.

This Court has referenced the “directly related” test only once, in Wilkes v. City 

of Greenville, 369 N.C. 730 (2017). There, we favorably quoted the test established in 

Pittman, as well as Pittman’s conclusion that the test is “[l]ogically implicit” in the 

structure of the Workers’ Compensation Act. Id. at 737. And, importantly, we also 

favorably discussed the focus on a causal connection between the condition for which 

treatment is sought and the workplace injury, citing Parsons and Perez. Id. at 740.

We noted that, when assessing medical compensation, the analysis turns on whether 

the “injuries or symptoms,” not the treatment, are “causally related to the admittedly 

compensable condition.” Id. at 741.

Despite these references to the Court of Appeals test, the holding in Wilkes

focused on separate issues, and the Court did not expressly adopt the Pittman line of 

cases. We therefore take this opportunity to formally endorse the test that developed 

in our lower appellate court and that we favorably recognized in Wilkes. This “directly 

related” test, with its focus on the causal connection between the condition to be 

treated and the workplace injury, safeguards the “rule of causal relation” that we 

have described as the anchor of the workers’ compensation system. Duncan, 234 N.C. 
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Opinion of the Court

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at 91.

Under this test, an employee may receive compensation for a medical 

treatment only if that treatment is directly related to the workplace injury, meaning 

there is a sufficiently strong causal relationship between the condition that requires 

treatment and the workplace injury. Wilkes, 369 N.C. at 737; Perez, 174 N.C. App. at 

133. Our case law examining causation in the workers’ compensation context offers 

guidance on how this causal relationship can be established. When examining how 

one injury, condition, or symptom could be causally related to another, we consider 

whether the former “caused, aggravated, or accelerated” the latter. Morrison v. 

Burlington Indus., 304 N.C. 1, 17 (1981).

In the context of a causal relationship between a condition to be treated and a 

workplace injury, these three factors can be articulated as three separate tests. First, 

a causal relationship exists when the workplace injury caused the condition for which 

treatment is sought. Second, a causal relationship exists when the workplace injury 

materially impacts the condition for which treatment is sought by aggravating that 

condition or causing new symptoms. Finally, a causal relationship exists if the 

condition was materially accelerated by the workplace injury—meaning the condition 

did not require medical treatment or intervention of any kind before the workplace 

injury but now requires treatment to aid in treatment of the workplace injury. See id.

at 18. 

If any of these criteria are met, the treatment is directly related to the 
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Opinion of the Court

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workplace injury and is compensable. If not, the treatment is, at most, indirectly 

related to the workplace injury and is not compensable under the workers’ 

compensation system. This causal standard ensures that, although the “employer 

takes the employee as he finds her with all her pre-existing infirmities and 

weaknesses,” medical compensation will be limited to conditions directly related to 

the workplace injury and will not “convert our compensation law into a system of 

compulsory general health insurance.” Id.

In this case, neither the Industrial Commission nor the Court of Appeals 

applied the test set out above. The Commission’s opinion and award examined only 

whether the bariatric surgery (the treatment) was “medically necessary” to achieve 

the requisite weight loss to undergo knee surgery. The Commission did not make any 

findings or conclusions concerning the causal relationship between plaintiff’s body 

weight issues (the condition) and the workplace injury.

The same is true of the Court of Appeals. The court focused on the treatment, 

not the condition, holding that “there is a direct line connecting the dots between 

Plaintiff’s original compensable injury and the Commission’s award for bariatric 

surgery.” Kluttz-Ellison, 283 N.C. App. at 214. Indeed, the Court of Appeals expressly

held that plaintiff’s body weight issues were not causally related to the workplace 

accident, emphasizing that “while the existence of Plaintiff’s weight problem was not 

directly related to the 5 August 2013 accident, the need for bariatric surgery is 

directly related.” Id.
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Because the lower courts did not apply the proper legal standard in this case, 

we reverse the decision of the Court of Appeals and remand with instructions to 

remand the matter to the Industrial Commission for further proceedings. See Pine v. 

Wal-Mart Assocs., 371 N.C. 707, 716–17 (2018).

REVERSED AND REMANDED.
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Riggs J., dissenting

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Justice RIGGS dissenting.

The Workers’ Compensation Act (the Act) mandates that medical 

compensation include services that “may reasonably be required to effect a cure or 

give relief and for such additional time as, in the judgment of the [Industrial] 

Commission, will tend to lessen the period of disability.” N.C.G.S. § 97-2(19) (2023). 

As the majority recognizes, this paints a broad brush, and understandably so; the 

facts of workers’ compensation claims are infinitely varied. No job is the same, no 

employee is the same, no accident is the same, no injury is the same, and no treatment 

is the same. And as the factfinders on the Industrial Commission can attest, even 

medical experts—to say nothing of judges—often disagree as to the cause, extent, and 

appropriate treatment of any given injury. While I understand the majority’s desire 

to judicially craft a uniform tripartite test and impose a “directly related” condition 

on an otherwise silent statute out of a desire to “k[eep] the Act within the limits of its 

intended scope,” Duncan v. City of Charlotte, 234 N.C. 86, 91 (1951), I am concerned 

that the means and end are at cross purposes. An unflinching and uniform test 

crafted by nonexpert appellate jurists seems all but guaranteed to end up excluding 

some unforeseen claims—whether due to lapses in our knowledge or imaginations—

that fairly fall within the language and intent of the Act. Indeed, as discussed below, 

it will exclude some claims foreseen both in the majority and this dissent. A test that 

excludes claims that the legislature intended to cover based on the Act’s text does not 
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Riggs J., dissenting

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in any real sense “k[eep] the Act within the limits of its intended scope.” Id. Because 

I do not believe the rigid test adopted by the majority is appropriate or necessary and 

because I believe the findings and conclusions of the Industrial Commission properly 

establish Ms. Kluttz-Ellison’s bariatric surgery as a treatment “reasonably . . . 

required to effect a cure or give relief” for a covered injury, N.C.G.S. § 97-2(19), I 

respectfully dissent.

The majority rightly notes that the Act is not, nor was it intended to be, a 

general health insurance policy. Morrison v. Burlington Indus., 304 N.C. 1, 11 (1981). 

And the Act does require a causal relationship between the injury and the workplace 

accident; specifically, the injury must be “by accident aris[ing] out of and in the course 

of the employment.” N.C.G.S. § 97-2(6) (2023); see also Gallimore v. Marilyn’s Shoes, 

292 N.C. 399, 402 (1977). It is this causal relationship between the injury and the

workplace accident that is the “very sheet anchor” of the Act to which the majority 

refers. Duncan, 234 N.C. at 91. 

As for compensable treatment, the relevant statute covers

medical, surgical, hospital, nursing, and rehabilitative 

services, including, but not limited to, attendant care 

services prescribed by a health care provider authorized by 

the employer or subsequently by the [Industrial]

Commission, vocational rehabilitation, and medicines, sick 

travel, and other treatment, including medical and surgical 

supplies, as may reasonably be required to effect a cure or 

give relief and for such additional time as, in the judgment 

of the [Industrial] Commission, will tend to lessen the 

period of disability; and any original artificial members as 

may reasonably be necessary at the end of the healing 
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Riggs J., dissenting

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period and the replacement of such artificial members 

when reasonably necessitated by ordinary use or medical 

circumstances. 

N.C.G.S. § 97-2(19) (emphases added). In other words, treatment is compensable 

under the Act if, in the view of a prescribing authorized healthcare provider, it is 

reasonably required to effect a cure or give relief to a covered injury or, in the 

judgment of the Industrial Commission, will lessen the period of a covered disability. 

Or, stated even more simply, if an authorized doctor believes the treatment is 

necessary to effect a cure or give relief of a workplace injury, then that treatment is 

compensable under the statutory text. To graft additional strictures into the Act, or 

to second-guess factfinders’ reliance on medical professionals’ expert judgments in 

unique circumstances, is not our province. See Lunsford v. Mills, 367 N.C. 618, 623 

(2014) (“[I]n effectuating legislative intent, it is our duty to give effect to the words 

actually used in a statute and not to delete words used or to insert words not used.”); 

Sprouse v. Mary B. Turner Trucking Co., 384 N.C. 635, 642 (2023) (“The North 

Carolina Industrial Commission is the fact-finding body under the [Act].”).

I acknowledge that we have imposed a “directly related” test in the context of 

future medical treatment for continued or additional symptoms. Wilkes v. City of 

Greenville, 369 N.C. 730, 737 (2017) (holding an employee seeking coverage for 

psychological symptoms after the employer had admitted compensability for physical 

injuries was entitled to a presumption that the psychological symptoms were related 

to his admittedly compensable conditions); see also Pittman v. Thomas & Howard, 
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Riggs J., dissenting

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122 N.C. App. 124, 130 (1996) (holding an employee was not entitled to additional 

compensation for a new condition when the evidence supported the Industrial 

Commission’s finding that the new condition was not related to a previously-covered 

injury); Parsons v. Pantry, Inc., 126 N.C. App. 540, 542 (1997) (holding an employee 

was entitled to a presumption that treatment of continuing headaches was causally 

related to prior covered headaches caused by a workplace injury); Perez v. Am.

Airlines/AMR Corp., 174 N.C. App. 128, 135 (2005) (holding a herniated disc 

discovered two years after last medical compensation for a covered workplace back 

injury was paid and four years since the covered accident occurred was causally 

related to that accident and injury). But that is not the circumstance we have here, 

this case involves a preexisting condition that must be treated in order to cure or 

relieve the covered workplace injury. Importantly, at least in the context of disability, 

this Court has acknowledged that if “pre-existing conditions such as an employee’s 

age, education and work experience are such that an injury causes him a greater 

degree of incapacity for work than the same injury would cause some other person, 

the employee must be compensated.” Little v. Anson Cnty. Schs. Food Serv., 295 N.C. 

527, 532 (1978). Not every employee that suffers a knee injury will require a total 

knee arthroplasty, and fewer still will require bariatric surgery prior to the 

arthroplasty. But the appropriate medical treatment for an injury is often unique to 

the employee, and if an authorized medical professional prescribes bariatric surgery 
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Riggs J., dissenting

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as “required to effect [the] cure” of arthroplasty for that employee’s covered workplace 

injury, then the bariatric surgery is compensable under N.C.G.S. § 97-2(19).

Though the majority’s uniform test has an inherent attraction, I cannot say it 

will avoid results inconsistent with the coverage contemplated by N.C.G.S. § 97-2(19). 

The majority’s own examples illustrate my concerns; in one abstract hypothetical, it 

suggests that an employee who changes treatment of a preexisting condition to help 

address pain from a new workplace injury would have those treatment changes for 

the preexisting condition covered. But it is hard to square that example with the 

majority’s distillation of its test into three circumstances: in the abstract 

hypothetical, (1) the workplace injury did not “cause[ ] the [pre-existing] condition for 

which treatment is sought”; (2) the workplace injury did not—at least at the level of 

abstraction offered by the majority—“aggravat[e] that [pre-existing] condition or 

caus[e] new symptoms”; and (3) it is not true that “the [pre-existing] condition did not 

require medical treatment or intervention of any kind before the workplace injury 

but now requires treatment to aid in treatment of the workplace injury.” While there 

are some specific instances where I might agree that the change in treatment for the 

preexisting condition is not covered because the new treatment itself does not further 

the aid “reasonably . . . required to effect a cure or give relief” from the covered injury, 

there are others—including those where the preexisting condition is neither 

aggravated or altered by the workplace injury itself—that would be covered under 

the statutory text consistent with the overall intent of the Act. A holding focused 
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Riggs J., dissenting

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more on crafting a uniform test rather than ensuring the purposes of the Act are 

carried out cannot—and the majority’s test does not—account for these 

circumstances.

Imagine a scenario that is slightly different from this case. A worker falls on 

the job, injuring her knee and requiring surgery to repair the injury. As part of the 

pre-operative workup, the medical team may order an echocardiogram to ensure that 

the patient does not have decreased blood flow to the heart prior to attempting the 

surgery. Roscoe N. Gray & Louise J. Gordy, Attorneys’ Textbook of Medicine, 

§ 30.42(1) (3d ed. 2010). If the test indicates a preexisting heart condition, previously 

diagnosed and controlled or mitigated in daily life by a low-dose aspirin regimen or 

similar noninvasive treatment, but which is too severe to allow for knee surgery 

without immediate invasive intervention, the health care provider may determine 

that it is medically necessary to immediately address the preexisting heart condition

through more invasive means as a prerequisite to the required knee surgery. And if 

the factfinders on the Industrial Commission credited adequate expert testimony 

consistent with that medical determination to find and conclude the heart condition 

treatment was compensable, that treatment would not be covered under the Act 

because of its mere existence—the hallmark of general health insurance—but 

because it had to be addressed in order to “effect a cure or give relief” for the covered 

injury, as demanded by statute. And yet, the majority’s three-part test would not 

cover that treatment because: (1) the heart condition had not been caused by the 
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Riggs J., dissenting

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workplace injury; (2) the injury itself did not aggravate the heart condition or create 

new symptoms; and (3) the heart condition had previously required some form of 

treatment.1

Stated differently, I would hold that whether a treatment is covered should 

turn on whether the particular facts of a case, as found by the Industrial Commission 

based on adequate competent evidence, demonstrate that the treatment was 

“reasonably . . . required to effect a cure or give relief and for such additional time as, 

in the judgment of the [Industrial] Commission, will tend to lessen the period of 

disability,” N.C.G.S. § 97-2(19), not on an extra-textual test that, in a noble effort for 

uniformity and predictability, may still not—and perhaps cannot—account for all 

circumstances intended to be covered by the legislature.

In these scenarios, the patient may require treatment for the preexisting 

condition, itself unrelated to the workplace injury in isolation, prior to and as a 

prerequisite for treatment of the workplace injury. Treatment of these preexisting 

conditions for the purpose of effecting a cure, giving relief, or lessening the period of 

1 Similarly, imagine an employee who suffers from allergies that are safely controlled 

in daily life by a regular over-the-counter antihistamine regimen and allergen avoidance. 

Then imagine that the employee requires a medication containing those allergens to treat or 

diagnose a workplace injury, e.g., intravenous contrast media for x-ray imaging; muscle 

relaxants; or aspirin. Roscoe N. Gray & Louise J. Gordy, Attorneys’ Textbook of Medicine, 

§ 65.42 (3d ed. 2010). The majority’s three-part test would not cover prophylactic 

epinephrine, steroids, or other treatments required to address those preexisting allergies’ 

response to the workplace-injury related treatments or medications—allergies that must be 

safely controlled in order to effectuate a cure of the workplace injury.
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Riggs J., dissenting

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disability of a covered workplace injury would not convert the Act into a general 

health insurance policy. It simply ensures that, pursuant to the stated goals of the 

statute, a treatment that cures, effects relief, or reduces the period of disability of a 

covered injury is compensable. And compensability under N.C.G.S. § 97-2(19) in 

these circumstances would accord with our caselaw establishing that the Act should 

be liberally construed to effectuate its purpose to provide compensation for injured 

employees and avoid denying benefits under technical, narrow, or strict construction 

of its provisions. See Hollman v. City of Raleigh, Pub. Util. Dep’t, 273 N.C. 240, 252 

(1968); Wilkes, 369 N.C. at 736–37.

As for the majority’s remand, Ms. Kluttz-Ellison sustained a compensable 

injury to her right knee due to a fall at work. The Industrial Commission found that 

the injury arose out of and during the course of employment. Both the health care 

provider and Industrial Commission agreed that Ms. Klutz-Ellison required a “right 

total knee arthroplasty” to effect a cure, provide relief, and/or lessen the period of 

disability” for this knee injury. After considering the testimony of several medical 

professionals as to the necessity of the prerequisite surgery to ensure the success of 

the arthroplasty, the Industrial Commission found that bariatric surgery was 

“medically necessary” as “a prerequisite to allowing [Ms. Kluttz-Ellison] to undergo 

the revision right total knee arthroplasty.” 

In sum, I cannot sign on to a uniform test that is not compelled by the statutory 

text and may result in the denial of intended coverage given workers’ compensation 
KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

Riggs J., dissenting

-22-

claims’ infinite permutations. The statute states that treatment prescribed by a 

medical provider as necessary to effectuate a cure of or relieve a workplace injury is 

compensable, and the Industrial Commission found that Ms. Kluttz-Ellison’s 

bariatric surgery was medically necessary to effect a cure, provide relief and/or lessen 

the period of disability of the covered knee injury. I would therefore affirm the 

decision of the Industrial Commission without remanding the case.

Justice EARLS joins in this dissenting opinion.