Brief Fact Summary. Katskee (Plaintiff) was genetically predisposed to cancer and Blue Cross/Blue Shield of Nebraska (Defendant) would not cover a surgery to remove organs from her.
Synopsis of Rule of Law. An insurance policy that is ambiguous will be interpreted in favor of the insured.
Where the terms of such a contract are clear, they are to be accorded their plain and ordinary meaning.View Full Point of Law
Issue. Will an insurance policy that is ambiguous be interpreted in favor of the insured?
Held. (White, J.)Â Yes.Â An insurance policy that is ambiguous will be interpreted in favor of the insured.Â An insurance policy is interpreted like any other contract.Â In this case, the question is regarding what exactly defines an illness as stated in the policy.Â Plaintiff’s cancer specialist holds the position that women from families with prevalent cancer history are more than 50 percent more likely to develop breast or ovarian cancer.Â There is only a one percent risk of the same cancers for the general population.Â Though the surgery was intended to prevent a possible future cancer, due to the weight of the odds against her, Plaintiff’s genetic condition is properly defined as an illness.Â Reversed and remanded.
Discussion. Conditions that precede illnesses will be caught more frequently as improvements are made in the sensitivity and technology used in medical diagnoses.Â Insurers will have to question how remote a risk will activate coverage.Â In particular, genetic advances will discover an ever growing list of risk factors for cancers and other diseases.