245 Neb.808 Supreme Court of Nebraska. SIndie Katsee,Appelleant, v BlueCross/Blue Shield of Nebra...

1. 1. Issues

1.1. Sindie Katskee wa diagnosed with a genetic condition known as breast-ovarian carcinoma syndrome.

1.2. Dr. Lynch, her primary doctor and Dr. Hoffman mutually recommended that the appellent should get a hysterectomy, removal of uterus, ovaries and the fallopian tubes. This was the normally recommended treatment for her condition.

1.3. The appllee, Blue Cross/Blue Shield initially indicated that they may pay for the surgery, but later denied the reimbursement.

1.4. Douglas County District Court gave a summary judgement against the appellent agreeing with the appelle that the condition did not constitute an illness and was not medically necessary.

1.5. The appellant then filed an appeal to the Nebraska Court of Appeals, which moved it to the Nebraska Supreme Court.

2. 2. Rules

2.1. The policy defined illness as a bodily disorder or disease, but did not define bodily disorder or disease.

2.2. If the policy is not clear then the Court may employ rule of construction. In this case the policy was ambiguous and so the rule is to favor the insured.

2.3. To decipher the meanings, the plain English meanings of the words using dictionaries are employed and the fanciful, curious or hidden meanings are not used.

3. 3. Analysis

3.1. Even though the breast-ovarian carcinoma syndrome can not be detected by genetic markers such as PSA for prostate cancer, the chances of developing the disease is 50% in comparison to 1.5% for someone who does not have this condition.

3.2. Appellent' s condition was considered an illness and a diseased state as we can not wait for the disease to develop after which it becomes to late for action.

3.3. Blue Cross/Blue Shield used Fuglsang v. Blue Cross, 235 Neb. 552, 456 N.W.2d 281 (1990) and explained that they had already explained what illness and disease was.

3.4. Dr. Mason, the chief medical officer for Blue Cross/Blue Shield had limited knowledge of cancer research and did not even consult with anybody. But he could not disagree with Drs. Lynch and Hoffman that the surgical procedure was the only course of action for someone who has breast-ovarian carcinoma syndrome.

4. 4. Conclusion

4.1. It was determined that Katskee's condition was an illness using simple English definitions according to the health insurance policy of Blue Cross/Blue Shield.

4.2. Furthermore, the requirement for genetic testing to prove illness is not valid.

4.3. The decision of the district court was reversed and remanded for further proceedings.