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Katskee v. Blue Cross/Blue Shield of Nebraska

245 Neb. 808, 515 N.W.2d 645 (1994)

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Katskee v. Blue Cross/Blue Shield of Nebraska

Nebraska Supreme Court

245 Neb. 808, 515 N.W.2d 645 (1994)

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Facts

Sindie Katskee (plaintiff) consulted Dr. Henry Lynch regarding her family’s history of breast and ovarian cancer. Lynch diagnosed Katskee as suffering from a genetic condition called breast-ovarian carcinoma syndrome and recommended that she undergo an operation to remove her uterus, ovaries, and fallopian tubes. Even though Katskee was diagnosed with a genetic condition with a high risk for developing cancer, Katskee did not have cancer. Prior to the procedure being performed, Katskee filed a claim with her insurance provider, Blue Cross/Blue Shield of Nebraska (BCBSN) (defendant). Additionally, Lynch and another physician wrote letters to BCBSN on Katskee’s behalf noting why the operation was needed. BCBSN mailed a letter to Katskee informing her that it “might” pay for the surgery. However Dr. Roger Mason, BCBSN’s chief medical officer, denied the claim two weeks before the scheduled operation. Mason stated it was not medically necessary and not covered under Katskee’s policy. Katskee proceeded to have the operation performed. After the operation, Katskee filed an action against BCBSN for breach of contract and sought to recover the costs of the operation. The district court granted BCBSN’s motion for summary judgment and held that Katskee did not suffer from cancer and although her heightened risk warranted the operation, it was not covered under her insurance policy. The district court also held that Katskee did not have a “bodily illness” or “disease” covered by the policy and that BCBSN reserved the right to determine what procedure or operation was considered “medically necessary.” Katskee appealed to the court of appeals and, on motion, the case was removed to the supreme court for consideration.

Rule of Law

Issue

Holding and Reasoning (White, J.)

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