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by John Allen, Professor of Law
University of Iowa, College of Law, Iowa
July 29, 1998

States began enacting workers' compensation laws in the early part of this century, and with the enactment of Hawaii's law in 1963, all states had, and now have, compensation laws. Workers' compensation laws have produced some remarkable decisions concerning assistive technology. An exploration of the structure of these laws is warranted both because the laws themselves can be a particularly fruitful source for the funding of assistive technology and because of the potential for translating the particular way of thinking about the nature of "medical care" embodied in these laws into other systems providing medical care.

With 50 different laws across the country, it can be difficult to make universal statements about workers' compensation law but there are some safe generalizations. The laws are intended to create a system by which individuals who are injured in connection with their work are provided a cash benefit and medical care. These benefits are paid for by the employer, typically through insurance written specifically to meet the obligations imposed by the state workers' compensation statute. The laws work an exchange: the injured employee receives benefits, but gives up the right to sue the employer.

The great majority of employees in this country are covered by workers' compensation laws. As of 1989, 87% of workers were covered. Some statutes exclude domestic employees, agricultural workers, and small firms.
The focus of these laws is on disability, measured by earning power. Payments, therefore, are tied to lost function.

All states require the provision of medical and hospital benefits, including "artificial members and aids". A number of interesting cases concerning assistive technology have arisen in connection with this obligation:
Squeo v. Comfort Control Corp., 99 N.J. 588, 494 A.2d 313 (1985).

The plaintiff in Squeo had quadriplegia, the consequence of a fall from a roof while working. The New Jersey statute required the provision of "medical, surgical or other treatment necessary to cure or relieve" the work-related injury, as well as other "appliances" to "restore the functions of the injured member or organ". The plaintiff sought payment for a self-contained apartment attached to the home of his parents, at a cost in excess of $65,000. The court found the expense to be "necessary" and "reasonable" and affirmed the order requiring payment for the construction of the apartment.
Quaker Oats Company v. Ciha, 552 N.W.2d 143 (Iowa 1996).

The plaintiff was involved in a motor vehicle accident while working, resulting in a broken neck and quadriplegia. The Iowa statute required the provision of medical care and "reasonable and necessary crutches, artificial members and appliances..." Mr. Ciha sought various home modifications, including widened doorways, a ramp, a special shower and an elevator to accommodate his use of a wheelchair. In addition, he sought the expenses of modifications to a van. Although the employer agreed to provide a wheelchair, it refused to provide the home and van modifications.

The Iowa Supreme Court affirmed the state workers' compensation agency's order that the employer pay for the home and van modifications. The court held that the modifications were "appliances", which the Iowa law defined to include any "artificial device used to provide function or for therapeutic purposes". The court viewed the modifications as designed to provide "function" for Mr. Ciha, concluding: "we believe the specific home modifications and van conversion are merely an extension of Ciha's wheelchair". As support, the court cited its earlier decision in Manpower Temporary Services v. Sioson, where the court held that a modified van is "not greatly different from crutches or a wheelchair", and that a van can be necessary to make a wheelchair "fully useful".
Courts in other states have split on the question of whether van modifications are covered. Some courts have held that these modifications are not medical care or appliances, while others have followed Iowa and ordered payment. Other cases have held that the employer must "reimburse a claimant for the difference between the purchase price of a van and the purchase price of a regular automobile".
Haga v. Clay Hyder Trucking Lines, 397 So.2d 428 (Fla.Dist.Ct.App.), review denied, 402 So.2d 609 (Fla. 1981).

In this case, the claimant lost both legs in an accident. His physician recommended swimming for needed cardiovascular exercise. The court affirmed an award of the costs of constructing an in-ground pool.
Braewood Convalescent Hospital v. Worker's Compensation Appeals Board, 34 Cal.3d 159, 193 Cal.Rptr. 157, 166 P.2d 14 (1983).

In this case, the claimant injured his back. The claimant weighed 422 pounds, and his physician recommended losing weight to facilitate recovery from his injuries. The claimant sought payment for admission to an in-patient weight loss clinic. The court held that it was appropriate to require payment for the treatment of a condition that must be treated in order to relieve the effects of the industrial injury. The court considered the treatment to be "medical" in nature.

These cases represent instances where individuals were able to obtain necessary equipment or devices that would never have been provided in connection with ordinary health insurance. In part, the difference can be explained by economics. The amount of workers' compensation benefits paid over time is dependent on the extent and duration of industrial disability. The longer the individual is away from work, the more the system pays. Technology that increases an individual's functioning has the potential, in the long run, to reduce the cost to the employer by enhancing the potential for the individual's return to the workplace.

It is worth exploring the possibility of importing this emphasis on function into other health care systems. The focus of health insurance has been, historically, on curative and palliative care. Any assessment of the quality of "health", however, must include consideration of function. The workers' compensation system, while relatively old, can provide a new model for thinking about what it means to provide "health care".

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