1. Issue
1.1. Determination of whether procedure was medically necessary
1.2. What constitutes an illness within health insurance policy
1.3. Ambiguity of policy-court to determine
2. Analysis/Application
2.1. Plaintiff
2.1.1. Plaintiff and Plaintiff's physicians believe hereditary conditions is an illness
2.1.2. Procedure should be covered because she exhibits breast-ovarian carcinoma syndrome
2.1.3. Substantial risk in developing cancer and often not discovered until it is too late
2.1.4. Decision to deny claim without submitting to review committee
2.2. Defendent
2.2.1. Plaintiff does not have cancer or any other illness
2.2.2. No current distinct symptom or condition of illness
2.3. Court
2.3.1. Determination of definition of illness
2.3.1.1. Fugslang definition of disease
2.3.1.1.1. When an illness exists, not whether the condition itself is an illness
2.3.2. Breast-Ovarian Carcinoma Syndrome is a physical state which deviates from the state of a normal, healthy woman
2.3.3. Plaintiff suffers from abnormal genetic constitution and combined with family history of hereditary cancer, which increases the risk of serious outcome.
2.3.4. Fine distinction between illness and predisposition to another illness
2.3.4.1. Silverstein v Metropolitan life Ins. Co., 254, N.Y. 81, 171, N.E. 914 (1930)...
3. Conclusion
3.1. Based on Blue Shield/Blue Cross terms, instering said condition (breast-ovarian carcinoma syndrome) into Fugslang definition, it is determined said condition constitutes an illness.
3.2. breast-ovarian carcinoma syndrome is present from genetic deviation and from family medical history
3.3. Medical evidence presented illustrates breast-ovarian carcinoma syndrome and plaintiff suffered bodily disorder or disease as defined in the insurance policy.
3.4. Blue Cross/Blue Shield not entitled to judgement.
3.5. Katskee's condition constitutes an illness within the definition of the policy.
3.6. Decision from lower court is reversed.
4. Importance
4.1. Health care professionals would be more inclined to recommend treatment for other patients
4.2. Definition of illness or disease is clarified for future issues and cases
4.3. Insurance providers will be more inclined to approve future claims based on definition of illness / disease
5. Facts
5.1. Parties
5.1.1. Sindie Katskee
5.1.1.1. Dr. Larry E. Roffman & Dr. Henry T. Lynch
5.1.2. Blue Cross/Blue Shield of Nebraska
5.1.2.1. Dr. Roger Mason
5.2. What Happened
5.2.1. Katskee Diagnosed with Genetic Condition
5.2.1.1. Dr. Lunch and Roffman Recommended procedures
5.2.1.1.1. Total Abdominal Hysterectomy
5.2.1.1.2. Bilateral Salpingo-Oophorectomy
5.2.2. Defendant originally said may pay for procedure
5.2.3. Dr. Mason determined BCBS would not pay for procedure
5.2.3.1. Katskee did not suffer from Cancer
5.2.3.2. Katskee did not have a bodily illness or disease
5.2.3.3. BCBS had right to determine medically necessary
5.2.4. Katskee had procedure regardless of denial
5.3. Procedural History
5.3.1. District Court, Douglas County, Paul J. Hickman summary judgement in favor of insurer
5.3.2. Insurer claimed procedure was not medically necessary
6. Rule of Law
6.1. definition of illness or disease
6.2. prior case rulings
7. Impact
7.1. Janet Fuglsang v Blue Cross of Western Iowa and South Dakota
7.1.1. Plaintiff diagnosed with myasthenia gravis
7.1.1.1. Blue Cross claims it was a pre-existing condition
7.2. Angela Proctor v Minnesota Mutual Fire & Casualty
7.2.1. Motor Vehicle Accident where Plaintiff wished to collect from her father's insurance company