1. 1. Facts
1.1. Parties
1.1.1. Sindie Katskee, Plantiff
1.1.2. Wyeth Inc., Defendant
1.2. What Happened?
1.2.1. Sindie Katskee was diagnosed with Breast-ovarian carcinoma syndrome by Dr Lynch which makes her genetically predisposed to getting breast and ovarian cancer. Due to the high risk of developing cancer, Dr Lynch and Dr Roffman recommended surgical removal of her uterus and ovaries.
1.2.2. Katskee was insured by Blue Cross Blue Shield (BCBS) who initially said they may pay for the procedure, but later told the patient it was going to be her responsibility despite both physicians explaining the necessity of the procedure to the insurer.
1.2.3. Katskee decided to have the surgery anyways and sued BCBS for breach of contract
1.2.4. Insurer denied claim stating that she did not currently have cancer, a bodily illness or disease covered by the policy, and that BCBS had the right to determine what was deemed medically necessary.
1.3. Procedural History
1.3.1. The district court ruled in favor of the insurer stating that she did not currently have cancer, a bodily illness or disease covered by the policy, and that BCBS had the right to determine what was deemed medically necessary.
1.3.2. Katskee appealed her case to the Nebraska Court of Appeals.The court was in agreement with Katskee that due to an error where an important fact was suppressed the case should be given summary judgement.
1.3.3. Case was reassigned to the Nebraska Supreme Court.
2. 2. Issues
2.1. Did Katskee's diagnosis qualify as an illness and should the procedure have been covered by her insurance ?
3. 3. Rule of Law
3.1. Decker v. Combined Ins. Co. of America
3.1.1. Ambiguity in insurance policy cases should rule in favor of the person who is insured.
3.2. Dalton Buick v. Universal Underwriters
3.2.1. Clear definitions and meanings of terms allow a contract to be stated in a simple and straightforward manner.
3.3. Silverstein v. Metropolitan Life Ins.
3.3.1. Difference between having a diagnosis of an illness v being predisposed to an illness.
4. 4. Analysis/Application
4.1. Plaintiff
4.1.1. Prophylactic surgery was warranted due to Katskee being part of a high risk population for developing cancer which was verified by two specialists in this field.
4.1.2. Family history was included and along with other significant risk factors showed that Katskee was at higher risk for developing this syndrome(50% v 1.4% in general population).
4.1.3. Genetic defects are considered to be abnormal and require treatment .
4.2. Defendant
4.2.1. Predisposition to a disease state does not necessitate that the person has or will have the disease.
4.2.2. There was no reason for the procedure to have been performed due to the diagnosis being based on a probability and not a current issue. Therefore no disease meant no breach in contract
4.3. Court
4.3.1. Definitions for certain terms such as "illness" and "bodily disorder" were deemed as an area for dispute but felt that illness was considered abnormal.
4.3.2. The surgery was covered due to it correcting a genetic defect which would lower the risk of the patient developing cancer.
5. 5. Conclusion
5.1. The judgement for the case was reversed due to ruling that the diagnosis received was within the meanings of the terms in question.
6. 6. Impact
6.1. Lindsay Manufacturing Co. v. Hartford Accident & Indemnity (1997)
6.1.1. Insurance contract was in question and the Katskee case was used to determine if common language was utilized.
6.2. Home Ins. Co. v. Aetna Ins. Co. (2001)
6.2.1. Dispute between two insurance companies about the wording on an insurance contract. The Katskee case was also used in this