1. Conclusion
1.1. The court held that Blue Cross/Blue Shield did not submit any evidence refuting the assumption that the origin of Katskee's condition was in the genetic makeup of the individual, and that in its natural development it was likely to create devastating results. The court found that the insurance policy was not ambiguous and applied plain and ordinary meaning to the terms of the contract. In view of the definition of plain and ordinary in regards to "illness," "bodily disorder," and "disease," the court found that Katskee's condition accounts as an illness within the meaning of the policy.
2. Impact
2.1. In the case of Lindsay Manufacturing Company v. Hartford Accident & Indemnity Company. Hartford and Lindsay came to an agreement that Hartford would reimburse Lindsay for cleanup expenses during the time of her policy coverage when she found out there was an environmental contamination problem arising from her manufacturing plant.
2.1.1. Hartford files a motion with the District Court against Lindsay, stating the "damages" do not include environmental costs. The District Court rejects Lindsay claims in favor of Hartford. Lindsay files a motion to appeal the decision due to the fact that the district court stopped Hartford from asserting a policy defense payment. The conclusion is determined from the Supreme Court of Nebraska reasoning in Katskee v. Blue Cross/Blue Shield. Under Nebraska law the interpretation of "damages" can be ambiguous under the general principle of construction. Therefore the policy covers environmental costs. The case is reversed and remanded.
2.2. In the case of Home Insurance Company v. Aetna Insurance Company. Home Insurance and Aetna Insurance settled a joint settlement claim for the University of Nebraska Board of Regents. Home Insurance argues that Aetna's Coverage A and Coverage O is ambiguous and that Aetna should pay an additional $250,000 toward the settlement. Under Nebraska Law the court must interpret the insurance policies contract and determine whether the contract is ambiguous.
2.2.1. The court referenced Katskee v. Blue Cross/Blue Shield whether the provision of the contracts is ordinary and reasonable for a person to understand them. The Court concludes that Aetna's Coverage A and Coverage is not separate and independent agreements. The policy is not ambiguous and Aetna is only liable for a single insurance settlement of $250,000.
3. Importance
3.1. A health care professional would care about the decision because it presents the importance of policy concerns. In regards to how much genetic information the insured must present in order for the insurers to cover their treatment. In addition to insurers inhibiting their clients genetic information as a reason for determining their health insurance premiums. Leading states to protect their citizens genetic information from being exposed.
4. Influence
4.1. Katskee v. Blue Cross/Blue Shield has revolutionized the ways of genetic testing and counseling. Referring patients to a genetic counselor to examine one's family health history and using genetic testing to detect the risk of cancer through saliva and blood testing. Providing options of coverage for these syndromes due to treatment advances over time.
4.2. Katskee v. Blue Cross/Blue Shield, has shown that once breast or ovarian cancer had been detected, treatment for the illness gets complicated. Katskee v. Blue Cross/Blue Shield made headway for the improvement of chemotherapy. For example High Dose Chemotherapy and Bone Marrow Treatment. Transforming the treatment of breast cancer in clinical practices changing the legislation on healthcare coverage and public policy. Driving women to advocate for proper treatment approval.
5. Citations
5.1. Katskee v. Blue Cross/Blue Shield of Nebraska, 515 N.W. 2d 645 (Neb.1994)
5.2. Lindsay Manufacturing v. Hartford Accident Indemnity Company, 911F. Supp. 1249 (D.Neb.1995)
5.3. Home Insurance Company v. Aetna Insurance Company, 236 F. 3d 927 (8th Cir. 2001)
5.4. Lucey C, Westphal JR. New approach to administrative medical decision-making: evidence-based medicine using high dose chemotherapy/bone marrow transplant for breast cancer. South Med J. 1998 Feb;91(2):196-201. PMID: 9496875.
6. Facts
6.1. Sindie Katskee (Appellant) v. Blue Cross/Blue Shield (Appellee)
6.2. Sindie Katskee was denied coverage for her surgery by Blue Cross/Blue Shield. Due to her not having an illness or disease that was covered by the insurance policy.
6.2.1. Dr. Larry E. Roffman, appellant's gynecologist, consulted with Dr. Henry T. Lynch, regarding Katskee family history of breast and ovarian cancer. Dr. Lynch diagnosed Katskee with breast-ovarian carcinoma syndrome after carefully examining and investigating her family history.
6.2.1.1. Women diagnosed with the syndrome have around a 50 percent chance or less of developing breast or ovarian cancer. Unlike women who are not affected have a chance less than 1.5 percent risk of developing breast or ovarian cancer.
6.2.2. Dr. Lynch and Dr. Roffman both recommended Katskee to have a total abdominal hysterectomy and bilateral salpingo-oophorectomy, due to Katskee having a high risk of receiving cancer, even though she did not have cancer at the time.
6.2.3. Blue Cross/Blue Shield intially indicated that it may pay for the surgery, but decided against the coverage two weeks before Katskee's surgery. Despite reading the diagnoses and explanations of both Dr. Lynch and Dr. Roffman's reasons for why they are recommending the surgery. Katskee went ahead with the surgery in November 1990.
6.3. The case originated in Nebraska, where Sindie Katsee filed an action for breach of contract in the District Court of Douglas County. The District Court dismissed the judgment in favor of Blue Cross/Blue Shield. Sindie Katksee filed an appeal to the Nebraska Court of Appeals, where the motion lead to the Supreme Court of Nebraska, that reversed and remanded the proceedings.
7. Issue
7.1. The issue is whether the appellant's condition of breast-ovarian carcinoma syndrome is considered an illness.
7.1.1. The Court is being called to determine the definition of what is an illness and whether the policy is ambiguous. Blue Cross/Blue Shield policy explicitly states that in order for the appellant to be covered for services the appellant must be experiencing an illness prior or at the time of the event in order to be covered.
7.1.2. When a statute is ambiguous, the meaning of the term may determine the outcome. Nebraska law governs the interpretation of the policy. Nebraska law treats an insurance policy like any other contract.
7.1.3. The Appellant was diagnosed with breast-ovarian carcinoma syndrome making the appellant a high risk needing a prophylactic surgery to prevent the arrival of cancer. The Court will consider the review of Dr. Lynch's deposition despite Dr. Mason's denial of the appellant claim.
7.1.3.1. Dr. Mason denied the appellant's claim lacking the knowledge of cancer research, without consulting with any medical researchers about breast-ovarian carcinoma syndrome. Dr. Mason made the decision without submitting the appellant claim to a claim committee for reviewal.
8. Rule of Law
8.1. Whether an insurance policy that is ambiguous be interpreted in favor of the insured.
8.1.1. The governing law for the issue is Statutory Law. Due to legal principles under Blue Cross/Blue Shield's policy that they may deem what is medically necessary for service coverage. Consistent with standards in the Medical Community of Nebraska.
8.1.2. The Court will use the contract to understand the terms regulated if they tie in with the rules of construction. The Court will use the language of “illness” and determine if the plain language can be understand by a reasonable person. By applying the principles of these terms found in dictionaries for example: Webster's Third New International Dictionary and Dorland's Illustrated Medical Dictionary. In addition to judicial opinions delivered by other courts to define the meaning of disease.