Katskee v. Blue Cross/Blue Shields of Nebraska

1. Facts of the Case

1.1. Sindie Katskee is appealing the decision of the district court of Douglas county after it ruled in favor of Blue Cross/Blue Shields (BCBS) of Nebraska

1.2. In 1990, Katskee's gynecologist, Dr. Larry Roffman recommended prophylactic total abdominal hysterectomy and bilateral salpingo-oophorectomy for breast-ovarian carcinoma syndrome (BOCS) diagnosed off family history at the time (as genetic testing for the syndrome had not yet been discovered or commercially developed). The patient elected to undergo the surgery at the advice of her physician later that year but Blue Cross/Blue Shield declined to pay for the surgery.

1.3. Katskee filed suit for breach of contract seeking ~$6,000 in costs for the surgery, but the the district court ruled in favor of BCBS as the the plaintiff did not have cancer and the policy covered treatment for bodily illness and disease which it ruled that Katskee did not have. Furthermore, the policy stipulates that BCBS withholds the right to determine whether a treatment is medically necessary and thus will reimburse for the procedure or treatment.

2. Rule of Law

2.1. Katskee's Insurance policy is subject to common and legislative contract law. The Court is able to make ruling in those areas which the contract language is found to be vague and thus open to interpretation.

2.2. At the heart of the dispute in this contract case is BCBS Health Insurance Policy definition of illness as bodily disorder or disease and whether Breast and Ovarian Carcinoma Syndrome meets this definition of illness.

3. Issue

3.1. Did BCBS break its contractual obligation to Katskee by not covering her prophylactic TAH and BSO for her diagnosis of Breast and Ovarian Carcinoma Syndrome?

4. Application & Analysis

4.1. While Katskee's BCBS Insurance Policy does provide the power for BCBS to determine medical necessity for coverage, the definition of illness in is sufficiently ambiguous to justify a court appeal to reconsider whether BOCS qualifies as illness covered by the policy or merely a predisposition to an illness

4.2. BOCS is a collection of genetic mutation(s) or variation that contributes to the increased susceptibility that manifests into breast of ovarian cancer. At the time of this case, diagnosis was performed via analysis and tracing of biological relatives cancer history. The SOC for women at increased risk of breast cancer is more frequent surveillance while those at high risk of ovarian cancer may require prophylactic surgery given the lack of early diagnostic tests and the high mortality rate of the cancer.

5. Conclusion

5.1. The Supreme Court of Nebraska ruled that given the genetic basis of disease and BCBS Insurance Policy's definition of illness, Katskee's BOCS constitutes bodily disorder or disease and reversed the lower court's decision that this treatment was not covered on the basis that Katskee did not have bodily disorder or disease. Breast and Ovarian Carcinoma Syndrome represents a genetic and biological aberration from normal and healthy function. This opens the case for further proceedings.