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Law Educator, Esq.
Law Educator, Esq., Lawyer
Category: Consumer Protection Law
Satisfied Customers: 116818
Experience:  Attorney experienced in commercial litigation.
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I am not sure if this is the right category. I have Aetna

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I am not sure if this is the right category. I have Aetna insurance through my employer. In going through a divorce my ex requested a custody evaluation and I requested we both have mental health evaluations completed. The custody evaluator recommended we both see a particular Psychiatrist for the evaluation. I called Aetna to see if this Dr. would be covered and they told me he is covered 100%. After the appointment I received a letter from Aetna that he is a non-contracted provider and is not covered at all. They tell me they have records of me being told that I would be covered 100%, but since he is not listed they are denying the claim. I filed an appeal and received a letter that they are denying the claim based on he is a non-contracted provider. They said nothing about their earlier conversation with me saying otherwise. I am allowed a second level appeal. What options do I have? What is my best approach? Thank you.
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.

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