Katskee v. Blue Cross/Blue Shield Of Nebraska

515 N.W.2d 645 (1994)

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Nature of the Case

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Facts

P consulted with Dr. Lynch regarding her family's history of breast and ovarian cancer, and particularly her health in relation to such a history. Dr. Lynch diagnosed her as suffering from a genetic condition called breast-ovarian carcinoma syndrome. Dr. Lynch recommended that P have a total abdominal hysterectomy and bilateral salpingo-oophorectomy, which involves the removal of the uterus, the ovaries, and the fallopian tubes. Dr. Roffman concurred and agreed that the recommended surgery was the most medically appropriate treatment. In preparation for the surgery, P filed a claim with D. D sent a letter and indicated that it might pay for the surgery. Two weeks before the surgery, D stated it would not cover the cost of the surgery. P had the surgery in November 1990. P then sued D for breach of contract, seeking to recover $6,022.57 in costs. D moved for summary judgment and it was granted. The court found that there was no genuine issue of material fact and that the policy did not cover P's surgery. The court stated that (1) P did not suffer from cancer, and although her high-risk condition warranted the surgery, it was not covered by the policy; (2) P did not have a bodily illness or disease which was covered by the policy; and (3) under the terms of the policy, D reserved the right to determine what is medically necessary. P filed a notice of appeal and the case was removed to the Nebraska Supreme Court.