AccountId: 011433970860
ContactId: 19747cd8-4551-41f0-9424-0e40dec7458d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1402869 ms
Total Talk Time (AGENT): 342795 ms
Total Talk Time (CUSTOMER): 427881 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=-1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/13/19747cd8-4551-41f0-9424-0e40dec7458d_20250613T14:37_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, I was calling because I was checking on a claim.
[CUSTOMER][NEUTRAL] You know my claim was saying 0 and I was trying to find out why.
[AGENT][NEUTRAL] OK, I can help you with claim status. Um, who am I speaking with?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And [PII], can I get a good call back number in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And do you have your policy number with you?
[CUSTOMER][NEUTRAL] Um, the last four is 9718. Let me see.
[CUSTOMER][POSITIVE] You hold on, I can get it for you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 0238
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 7081
[AGENT][NEUTRAL] Alright, give me just a second while I look that up, OK?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And can you verify your date of birth for me, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the address that we have on file for you?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Alright, thank you so much.
[AGENT][NEUTRAL] All right, let me look here.
[AGENT][NEUTRAL] Do you know what the claim number is?
[CUSTOMER][NEUTRAL] Mm, hold on.
[CUSTOMER][NEUTRAL] 360
[CUSTOMER][NEUTRAL] 971 8
[AGENT][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] Let me look here.
[AGENT][NEUTRAL] It looks like the condition that you filed the claim under isn't covered under this plan.
[CUSTOMER][NEUTRAL] OK, I, I have critical care and I had a heart attack.
[CUSTOMER][NEUTRAL] So, why that's not covered?
[AGENT][NEUTRAL] Alright, let me look. Let me look at your policy real quick.
[AGENT][NEUTRAL] You said you had a heart attack?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, give me just one moment, let me see if I can get someone from claim support real quick, OK? One moment.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Morning. Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, [PII]. This is [PII] from the care team. I have a Miss [PII] on the line. Um, it looks like her claim got denied. Um, it said that the, um, what they billed for or whatever, the, the illness isn't covered under her policy, but then when I looked under the policy cause she said it was a heart attack, I'm showing that it's covered, so I was wondering if you could help me out um and look into what she
[CUSTOMER][NEUTRAL] What's the policy number?
[AGENT][NEUTRAL] OK, it's 23.
[AGENT][NEUTRAL] 87
[AGENT][NEUTRAL] 081.
[AGENT][NEUTRAL] And it's that second claim, uh, ending in 9718.
[CUSTOMER][NEUTRAL] I'm just trying to see what we got in.
[CUSTOMER][NEUTRAL] So you said, she said she had a stroke, you said?
[AGENT][NEUTRAL] Heart attack?
[CUSTOMER][NEUTRAL] Heart attack? OK. Let's see here.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, it looks like she sent it 3 times.
[CUSTOMER][NEUTRAL] Yeah, I'm trying to see what the policy wording says regarding that benefit.
[CUSTOMER][NEUTRAL] Mm, these other documents that she sent other documents as well.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Give me one moment. I'm gonna put you on a brief hold while I check something further.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Thank you for holding. Yeah, it looks like based off the information that we have, it's not covered because it does not meet the policy provisions of a heart attack. Looks like based off the information she sent to us, her heart test results were in normal range.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So it does not meet the definition of a heart attack within the policy.
[AGENT][NEUTRAL] OK, let me write that down or do you want me to transfer her to you?
[CUSTOMER][NEUTRAL] You can let her know.
[AGENT][NEUTRAL] OK. Um, so you said it wasn't covered because what was in a normal range?
[CUSTOMER][NEUTRAL] It looks like that her test results were in normal range and it does not meet the definition of a heart attack within the policy.
[CUSTOMER][NEUTRAL] And then within the policy, it has a verbiage for heart attack.
[CUSTOMER][NEUTRAL] Which will result in blockage and it looks like based on the information we have.
[CUSTOMER][NEGATIVE] It does not meet that qualification for that heart attack.
[CUSTOMER][POSITIVE] Benefit under the plan.
[AGENT][POSITIVE] OK, I'll let her know. Thank you so much.
[CUSTOMER][POSITIVE] OK. You're welcome.
[AGENT][NEUTRAL] Alright bye.
[CUSTOMER][NEUTRAL] Mm bye.
[AGENT][NEUTRAL] [PII], are you still there?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It looks like it was denied because your policy, the way it's defined as a heart attack, includes blockage. um, and it looks like because the, the test results that you sent in showed that your results were in a normal range, it doesn't meet the definition of a heart attack.
[CUSTOMER][NEUTRAL] OK, well, if it's only saying I had a heart attack, what do you mean I didn't have one?
[AGENT][NEUTRAL] It doesn't meet your policy's definition of a heart attack. Let me pull it up.
[CUSTOMER][NEUTRAL] OK, well on the policy they just have a heart attack.
[CUSTOMER][NEUTRAL] I've seen that, that's what y'all pay for a heart attack. It didn't see with any kind of stipulations, they have a heart attack.
[CUSTOMER][NEGATIVE] They even had on there before I went in the ambulance and all that. I didn't get paid for anything, nothing.
[AGENT][NEUTRAL] Yeah, it
[AGENT][NEUTRAL] Yeah, it looks like on page.
[CUSTOMER][NEUTRAL] I put in the hospital 3 days.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What, what about that money from staying in the hospital, going in the ambulance, taking all these tests.
[CUSTOMER][NEUTRAL] So y'all telling me that I didn't have a heart attack.
[AGENT][NEUTRAL] Yeah it looks like it was um.
[AGENT][NEUTRAL] On page 19, it has the definition of your of a heart attack and it shows, um, and one of the definitions shows that uh EKG findings are consistent with a myocardial infarction and your test results uh were in a normal range.
[AGENT][NEUTRAL] And then it says elevation of cardiac.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] You're telling me about a test result.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So when they say that I had a insemia or whatever, it's considered a heart attack, so y'all don't look at that.
[AGENT][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] Yes, ma'am. It shows that um
[AGENT][NEUTRAL] Your test results will need to be above or uh will need to be levels that aren't normal for any of those tests that you um sent in and yours were in the normal range.
[CUSTOMER][NEUTRAL] OK, but ma'am, if that happened, the test was in the normal range after the fact. What about the fact when I had the heart attack? Evidently it was not normal at that time.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] I had a heart attack and I don't have anything in writing telling me all that what you said. Only thing that critical claim says for a heart attack, y'all pay $10,000. They don't have anything in writing telling me what you're saying.
[AGENT][NEUTRAL] Well, I'm, I'm reading it from your policy document.
[CUSTOMER][NEUTRAL] So that seem like fall to me.
[CUSTOMER][NEUTRAL] OK, I don't have that. Only thing I have is a list of the critical care and what it pays for a heart attack and all other stuff y'all have in parentheses, um, stipulations or whatever it may be. By a heart attack, it just have a heart attack. It don't have none of that.
[CUSTOMER][NEGATIVE] It don't have anything about the ambulance. All the tests I took, y'all supposed to pay me for being in the hospital. I didn't get paid for anything.
[CUSTOMER][NEGATIVE] So now you're telling me because of test result I took after a heart attack, y'all can't pay me?
[CUSTOMER][NEUTRAL] That's what you're telling me?
[AGENT][NEUTRAL] Well, if you have the test results from before your heart attack that shows that your levels weren't in normal range, uh, send that in.
[CUSTOMER][NEUTRAL] I gave you test results after the uh for the test results I had in the hospital.
[CUSTOMER][POSITIVE] That's what I gave y'all.
[AGENT][NEUTRAL] Well, if you would like, um,
[CUSTOMER][NEUTRAL] I didn't give you anything before the heart attack.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] If you would like, um, so in your policy, it does state, um, what a, what is considered to be a heart attack. It also does state, um, how to file an appeal and if you would like
[CUSTOMER][NEGATIVE] So you telling me what y'all saying on the computer, what it says to me, because when I got the policy and I've been paying it faithfully, it does not tell me that. It says a heart attack.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That's all it says to me.
[AGENT][NEUTRAL] And if you, if you scroll further down in your policy document, it does have the definitions in there.
[CUSTOMER][NEUTRAL] So what is, I'm, I'm not, I'm confused. So if you have a heart attack.
[CUSTOMER][NEUTRAL] And y'all say that's what y'all pay for critical care.
[CUSTOMER][NEUTRAL] Why is whatever about whatever test results or whatever you're saying?
[CUSTOMER][NEUTRAL] I'm thinking that I'm getting paid for having a heart attack.
[AGENT][NEUTRAL] Yes, ma'am, but in your policy, it has a definition of a heart attack and that didn't meet the definition.
[CUSTOMER][NEUTRAL] What's the definition of a heart attack?
[CUSTOMER][NEUTRAL] If a heart attack is a heart attack, what do you mean the definition of a heart attack?
[AGENT][POSITIVE] Well definition.
[CUSTOMER][NEGATIVE] If I went by ambulance to the hospital and had a heart attack, and you telling me it's a definition of a heart attack, a heart attack is a heart attack.
[CUSTOMER][NEUTRAL] And that's what I was paying for the critical care.
[AGENT][NEUTRAL] Like, well, there.
[CUSTOMER][NEGATIVE] So where is my money for going in the ambulance? Where's my money for all the test results? Where's my money for staying in the hospital? Where's that money?
[AGENT][NEUTRAL] You do have the right to appeal this decision if you would like. Um, you will just need to send an
[CUSTOMER][NEUTRAL] No, I'm asking a question.
[CUSTOMER][NEUTRAL] I'm asking a question.
[CUSTOMER][NEUTRAL] That's part of the pile that's in there too.
[AGENT][NEUTRAL] Because
[CUSTOMER][NEUTRAL] About going in an ambulance. Where, where is that money?
[CUSTOMER][NEUTRAL] There's a stipulation for that too?
[AGENT][NEUTRAL] Yeah
[AGENT][NEGATIVE] It looks like ambulance rides aren't covered in this. It will be a lump sum.
[CUSTOMER][NEUTRAL] What?
[CUSTOMER][NEGATIVE] So I don't get paid for the hospital stay, none of that that's in the thing that I pay for.
[CUSTOMER][NEGATIVE] So it seem like I have to get an appeal and get an attorney to get my money because that's not what I have.
[CUSTOMER][NEUTRAL] Y'all gave me a list of what's covered. That's what I have.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] What I paid for, and now you telling me if I go on the ambulance, it's whatever. That don't, that don't say that by ambulance. They don't say that by hospital stay.
[AGENT][NEUTRAL] Right. And hospital stays, none of that is in this policy, but it does have the definition of a heart attack um after the benefits where it showed all of the amounts, uh, based, based off of each critical illness. When you go down further because it's it's 38 pages. So if you scroll down to, I think the 19th page, that's where it shows the definition of a heart attack, and that's in your policy document. That is in your policy certification.
[CUSTOMER][NEUTRAL] What you saying?
[CUSTOMER][NEUTRAL] Oh, I want, I want, I want a pill.
[AGENT][NEUTRAL] OK. Uh.
[CUSTOMER][NEGATIVE] Because I, you're telling me about 38 pages. I don't have no 38 pages. What I've seen at my job and I'm going to my job and I'm gonna have them have a problem with Crescent City because it seems like this is fraud.
[CUSTOMER][NEUTRAL] Because this was not given when we, when we signed up for that and they say critical care, this is saying this is what we get paid for.
[CUSTOMER][NEUTRAL] Now, you telling me about um a definition of a heart attack.
[CUSTOMER][NEUTRAL] I'm saying a heart attack is a heart attack. What you're saying, it does not matter. I had a heart attack.
[CUSTOMER][NEGATIVE] And you telling me about test results after the fact. Then you tell me about the ambulance and all this stuff that's listed to get paid. It does not say about no combination or nothing like that.
[CUSTOMER][NEGATIVE] So that to me that's like false advertising.
[CUSTOMER][NEGATIVE] When they come out to the job and give us that information, they don't tell us nothing on the side about if you have a heart attack, about what the test results shows after. If I give you some stating I had a heart attack, y'all supposed to pay me.
[AGENT][NEUTRAL] Do you have
[CUSTOMER][NEGATIVE] I went in the ambulance. I had tests. Y'all supposed to pay for the different tests. I ain't getting that $1.
[AGENT][NEUTRAL] Would you like
[CUSTOMER][NEGATIVE] And I don't think that's fair.
[CUSTOMER][NEUTRAL] And I want to appeal and I'm gonna have my and what's your name? [PII] what?
[AGENT][NEUTRAL] [PII] is my last initial.
[CUSTOMER][NEUTRAL] OK, well, what is your last name? You don't give out the last name?
[AGENT][NEUTRAL] I'm not gonna give you my last name, no, ma'am.
[CUSTOMER][NEGATIVE] So now you have an attitude because I'm telling you what I'm I'm about me having a heart attack.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] I don't have an attitude, ma'am. I'm just not telling you my last name. I'm not giving you that, I'm not giving you my last name. I can give you what you need to file an appeal if you would like.
[CUSTOMER][NEUTRAL] Oh yeah, I want, I want the information of all appeal.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you have a pen and paper ready? OK.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Yes, I do.
[AGENT][NEUTRAL] OK, so you will want to in writing um explain uh why you would like to appeal. You'll need to be specific in the reason for the determination why you believe that we denied the claim, why you believe that that shouldn't have happened.
[AGENT][NEUTRAL] You'll want to uh reference any plan provision um that had that benefit. So as you were stating earlier, uh the lump sum, why you believe you, um.
[CUSTOMER][NEUTRAL] OK, just give me what I, who I need to send it to cause the attorney could do all that. I need, I just need to know who I need to send it to.
[AGENT][NEUTRAL] OK. Um, it's
[CUSTOMER][NEUTRAL] The information when I do the appeal.
[AGENT][NEUTRAL] It'll be at APL attention uh [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII] and what else behind it?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Do they have an email?
[AGENT][NEUTRAL] Uh, it won't go through email, but I can give you the fax number because the email isn't secure and so our mailing and our fax number is secured.
[AGENT][NEUTRAL] Our fax number is.
[CUSTOMER][NEUTRAL] What's the fax number?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] 365.
[AGENT][NEUTRAL] [PII].