Determining Hernia Coverage

By Staci Cassidy, senior vice president, PartnerSource

PartnerSource injury benefit plans afford medical coverage for those injuries and for conditions that directly and solely result from the course and scope of employment -- with a few exceptions. Consistent among the few exceptions are criteria that, if satisfied, indicate the work activity, although not the direct and sole cause of the injury, is to a reasonable degree of medical probability a major contributing cause. Hernias are one such exception.

Hernias result from a combination of: (1) an opening or weakness of the abdominal muscle or connective tissue and (2) pressure. A hernia occurs when an abdominal organ, intestine or fatty tissue squeezes through an opening or weak spot in a surrounding muscle or tissue.

The opening or weakness may be present at birth or may result from abdominal-related surgery. Most often, the weakness occurs over time as the result of poor nutrition and obesity, which can worsen through smoking.

The greater the weakness of the muscle or tissue, the less pressure is needed to result in a hernia. A sneeze, cough, constipation, and lifting something not very heavy could be enough.

Therefore, on one side, there is a contributing underlying non-occupational defect (the opening or weakness in the abdominal muscle or tissue) and on the other side, some alleged contributing exertion or "pressure" from a work activity. The side on which the evidence weighs heavier determines whether there is coverage, and notably the evidence should include a medical judgment by a peer review physician.

Assume we have a 6’2", obese male with a BMI of 36, who, as part of his normal job duties, lifts a 30-pound box and feels a slight pull in his right groin. Clinical exam and an ultrasound identify a small right inguinal hernia and a small periumbilical hernia, an area where he has no complaints.

The foregoing evidence proves the work activity was at most a very minor contributing cause of the hernia as compared to the weak abdominal muscle or tissue. This man’s BMI is significant for likely weakening the abdominal muscle and tissue. The second hernia, where he has no complaints, is further evidence that the muscle or tissue was so weak that minimal pressure resulted in a hernia. Finally, it would not take much exertion for a man of his size to lift a 30-pound box. If, in fact, the hernia occurred during this lift, the muscle or tissue in this area had to be very weak.

Let’s suppose the injured worker then sues the employer for negligence. To prevail, the employee must prove the employer’s negligence proximately caused the hernia. Proximate cause requires the employer’s conduct to be a substantial factor in bringing about the hernia, and without which the hernia would not have occurred. The same rational as used in determining benefit coverage would also apply. The lifting was not a substantial factor in bringing about the hernia.

PartnerSource is here to help. For more information on hernia claims, please contact Staci Cassidy.

[1][2][4] Reed Group MD Guidelines 

[3] AMA Guides to the Evaluation of Disease and Injury Causation 2nd Edition