Thank you for your question. I look forward to working with you to provide you the information you are seeking for educational purposes only.
Unfortunately, unless you received from them in writing something saying you would be covered with this doctor, legally a verbal statement of an employee cannot be used to alter the terms of an insurance plan description. I am afraid we run into this all of the time where insurance employees on the phone mistakenly tell customers they have coverage and when the plan is checked when the bill comes in they are found to not be covered for that issue and the courts hold that if the promise to pay was not in writing it was not enforceable because an employee cannot change a contract unless it is changed in writing.
Thus, you can argue with them in your second appeal that you specifically asked about this particular doctor and their employee told you he was covered under your plan and you acted in reliance on their representation to you that he was covered in your plan. However, ultimately if these cases go to court, the courts are forced by wording of the contracts to follow the contracts without any other writing to change the contract.
I truly aim to please you as a customer, but please keep in mind that I do not know what you already know or don't know, or with what you need help, unless you tell me. Please consider that I am answering the question or question that is posed in your posting based upon my reading of your post and sometimes misunderstandings can occur. If I did not answer the question you thought you were asking, please respond with the specific question you wanted answered.
Kindly remember the ONLY WAY experts receive any credit at all for spending time with customers is if you click on OK, GOOD or EXCELLENT SERVICE even though you have made a deposit or are a subscription customer. YOU MUST COMPLETE THE RATING FOR THE EXPERT TO RECEIVE ANY CREDIT.
Also remember, sometimes the law does not support what we want it to support, but that is not the fault of the person answering the question, so please be courteous.
This is NOT the practice of law nor is it legal advice to you, it is merely educational information for you to use to seek out a licensed attorney in your state to get actual legal advice from them. Please use sites such as http://www.martindale.com or http://www.lexmundi.com or http://www.hg.org to find a local attorney to get actual legal advice in all matters.