AccountId: 011433970860
ContactId: 00d252b7-ea3c-4df1-80d8-4df3c2c84d4d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 358570 ms
Total Talk Time (AGENT): 150996 ms
Total Talk Time (CUSTOMER): 153079 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/00d252b7-ea3c-4df1-80d8-4df3c2c84d4d_20250226T20:13_UTC.wav
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[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, hi, um, I'm [PII]. I, I, I.
[CUSTOMER][NEUTRAL] I'm also here with my mom who's uh [PII], who's helping me. And I
[CUSTOMER][NEGATIVE] Had a claim that was processed on the [PII] and apparently denied um.
[CUSTOMER][NEUTRAL] And uh we were wondering if we could just get more information about why it was denied.
[AGENT][NEUTRAL] Sure, I can take a look at that and what's a good callback number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you and what's the policy number?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um, 02500346.
[AGENT][NEUTRAL] Alright, thank you and verify your address and date of birth.
[CUSTOMER][NEUTRAL] [PII], and date of birth [PII].
[AGENT][NEUTRAL] Thanks, [PII], and also verify your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright, thank you for verifying that information and you're calling in regards to your claim you want additional information?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. All right, sure. Bear with me just a moment. I'll take a look at that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] All right. So I show that uh claim processed on [PII], and that claim uh denied as preexisting, stating that the uh condition you're filing for is found to be pre-existing, and so it's not covered.
[CUSTOMER][NEUTRAL] OK, so, um, what I need to, what we need to understand is what specifically about the claim application were you pointing to when you said it was preexisting because most of these um causes of the disability did not happen until after [PII].
[AGENT][NEUTRAL] Yes, and um.
[AGENT][NEUTRAL] Due to the policy effective date of [PII], there's a pre-existing period, which is one year prior to the policy effective date. So if there was anything related to the diagnosis you're filing for, um, any visits, any, anything from a medical provider, um, advice related to that diagnosis, then that would be considered pre-existing.
[CUSTOMER][NEUTRAL] OK, so if she didn't have um gas uh GI problems or vision problems or abdominal and pelvic pain.
[CUSTOMER][NEUTRAL] Before [PII], doesn't that count as the disability?
[AGENT][NEUTRAL] I'm not sure I understand your question.
[CUSTOMER][NEUTRAL] Well, there are a number of conditions that she has and yes some of them are related to functional neurological disease or disorder, but many of these which are really causing the problem are GI problems um.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Vision disturbance, abdominal problems, pelvic pain, anxiety, fatigue, all of that stuff is happening after [PII].
[CUSTOMER][NEUTRAL] When the policy was taken out.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So yes,
[CUSTOMER][NEUTRAL] FND is is before [PII] we understand that, but these other things that are really causing a lot of the problems happened after.
[AGENT][NEUTRAL] OK. So yeah, you do have the option to file an appeal with uh supporting documentation and in regards to the diagnosis, but based on the information we received uh on the current claim, that is the claim decision. But again, you can file an appeal if you don't agree with that claim decision.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so, um, what kind of other documentation do you need?
[AGENT][NEUTRAL] Mm, anything from uh the provider, uh, from the doctor, um, but more information than what we've received. I can't, I'm not sure specifically what that would be in your case, but it would just be something to support what you're stating to me on the phone, um, because the, the claim information received, uh, was reviewed and that was the claim decision.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, all right.
[CUSTOMER][POSITIVE] Thank you very much.
[AGENT][POSITIVE] No problem. Is there anything else I can help you?
[CUSTOMER][NEUTRAL] Now where where yeah where do we go to get the appeal form?
[AGENT][NEUTRAL] There's no appeal form. You'll just send in that information and note, uh maybe a letter or something that notes that you're appealing the claim decision and um our appeal appeals department will take care of that and you'll submit it the same way uh you did with the initial claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you. That answers our questions.
[AGENT][POSITIVE] No problem. Alright, good deal. Well thank you for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thanks.
[AGENT][NEUTRAL] Uh-huh, bye bye.