Court Opinion

ID: 9953664
Source: CourtListenerOpinion
Date Created: 2024-03-22 16:09:32.912431+00
Date Added: 2024-06-11T08:02:00.593462
License: Public Domain

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.
                  KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

                                   Opinion of the Court

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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                   KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

                                   Opinion of the Court

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

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 weight-

loss 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

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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                                  Opinion of the Court

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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                                   Opinion of the Court

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

“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

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

                                            -9-
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                                  Opinion of the Court

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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                    KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

                                    Opinion of the Court

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

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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                 KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

                                 Opinion of the Court

      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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                  KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

                                    Riggs J., dissenting

      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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                  KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

                                    Riggs J., dissenting

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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                  KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

                                   Riggs J., dissenting

             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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                  KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

                                   Riggs J., dissenting

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

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

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

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.

                                           -20-
                  KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

                                   Riggs J., dissenting

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

                                          -21-
                  KLUTTZ-ELLISON V. NOAH’S PLAYLOFT PRESCHOOL

                                   Riggs J., dissenting

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.

                                          -22-