Medical Expertise PC v. Trumbull Insurance Co.

Judge Siegal

MEDICAL EXPERTISE, P.C. v. TRUMBULL INSURANCE COMPANY — This action was commenced by a provider of psychological services Plaintiff Medical Expertise, PC, as assignee of Irina Moukha, against Defendant Trumbell Insurance Co. seeking a judgment for unpaid claims filed pursuant to New York’s No Fault Insurance law. On August 7, 2000, Plaintiff filed a claim with Trumbull Ins. Co. for psychological services rendered to assignor Moukha, purportedly as a result of a July 9, 2000, motor vehicle accident, seeking full reimbursement for services provided on July 11, 2000 including Psychiatric Evaluation of Records ($67.24) ; psychiatric diagnostic interview ($194.58) and five psycho diagnostic tests with interpretations and report ($139.30 for each of the five tests); explanation and interpretation of results to primary physician ($103.31) rendered on July 18, 2000 and one psychotherapy session held on August 1, 2000 ($120.00). The diagnosis listed was “Acute Stress Disorder.” The claim included an assignment and authorization and a Self referral consent and authorization form both executed on July 11, 2000. The following psycho diagnostic tools were administered: TESI (Tramuatic Event Sequelae Inventory), BDI (Beck Depression Inventory), BAI (Beck Anxiety Inventory), BHS (Beck Hopelessness Inventory), SS-77 (Psychiatric Symptom Check List), NSC (Neuro-psychological check list) and Mental Status Examination. A letter of medical necessity issued by Plaintiff was also included. Defendant insurer denied the claim on the basis of a peer review. Both the Plaintiff’s provider, Dr. S. Trier, and Defendant’s Peer Review psychologist, Dr. Bruce Fisher, testified at trial. The Peer review psychologist never interviewed the assignor, rather he rendered his decision to deny the claim on the basis that the psycho-diagnostic tools were used prematurely. For example, in the Beck Inventory, a question is posed “how have you been feeling for the past seven days?” In addition, Dr. Fisher was critical of using diagnostic tests instead of personal interviews.