AccountId: 011433970860
ContactId: 198a8aa9-883b-4b36-adcc-1e7aeb6e3ab0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1017309 ms
Total Talk Time (AGENT): 703262 ms
Total Talk Time (CUSTOMER): 283545 ms
Interruptions: 5
Overall Sentiment: AGENT=0, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/07/198a8aa9-883b-4b36-adcc-1e7aeb6e3ab0_20250107T19:32_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] over on the care team. How are you today?
[AGENT][POSITIVE] I'm good. How are you, [PII]?
[CUSTOMER][NEUTRAL] Doing all right thank you. I actually just got off with [PII] um the same insured, um, I think he's gonna have to talk to y'all though he's um.
[CUSTOMER][NEUTRAL] Essentially he filed a claim for an accident. We denied it as there was no bodily injury. He sent in an appeal with all kinds of information stating that it was, and from what [PII] told me was essentially that decision was upheld that it was not a bodily injury for his policy, and so he's arguing with me about that, so I'm not quite sure.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, what's the policy?
[CUSTOMER][NEUTRAL] It is 991306.
[CUSTOMER][NEUTRAL] Sorry to dump this on you.
[AGENT][NEUTRAL] No, it's OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You're not being mean or anything, just, you know.
[AGENT][NEUTRAL] Yeah, just
[CUSTOMER][NEGATIVE] Yeah, [PII].
[AGENT][NEUTRAL] It's, yeah, and these, um these accident policies like.
[AGENT][NEUTRAL] You know, it's, it's hard because we're not saying, of course, that they didn't have an accident. Like it's not, we're not saying you didn't fall and whatever. It's just that per your language, it, it just doesn't meet the definition.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Exactly.
[CUSTOMER][NEUTRAL] Exactly, and again I think that's where it, it could be lost in interpretation as well, so.
[AGENT][NEUTRAL] Yeah, for sure. OK, so I've got.
[AGENT][NEUTRAL] All of that. I've got the appeal pulled up and I've got the claim pulled up so.
[CUSTOMER][NEUTRAL] The original OK
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] I went to the ER, slipped in water, hurt his knee, and twisted his back.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I think I remember going over this one with [PII] before she responded.
[AGENT][NEUTRAL] And the biggest reason for it.
[AGENT][NEUTRAL] was because everything they have is pain. They're not saying.
[CUSTOMER][NEUTRAL] That's, yeah. That's what um [PII] told me. That's what I told him, but he said that he included doctor's notes in there for when he, he went to receive treatment, but again, um, if it was just, you know, pain medicine or something, I'm not quite sure.
[AGENT][NEGATIVE] That he actually injured himself.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let's see, OK, um, presents do.
[AGENT][NEUTRAL] For evaluation of pain in the knee and back.
[AGENT][NEGATIVE] Slipped and fell.
[AGENT][NEGATIVE] Uh, landed on his knee, twisted his back, did not hit his head, started having pain.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK. Again, just pain.
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] Did a
[AGENT][POSITIVE] Physical exam, no deformities.
[AGENT][NEGATIVE] Doesn't mention any type of bruising.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Evaluated for acute fracture versus a sprain.
[AGENT][NEUTRAL] says that they suspect his pain is secondary to a muscle spasm.
[AGENT][NEUTRAL] Which again is not.
[CUSTOMER][NEUTRAL] Right, not due to an accident, yeah.
[AGENT][NEUTRAL] An accident.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Believe his back pain is muscle spasm. There were no fractures. Do not believe he is having an acute spinal pathology given there's no tenderness.
[AGENT][NEUTRAL] It says that I believe his left knee pain is either sprain or contusion since there's no fracture, but he did not diagnose him.
[AGENT][NEUTRAL] And I remember
[AGENT][NEUTRAL] Um, [PII] going over that and I said, you know, if he would have said that there was.
[CUSTOMER][NEUTRAL] Weird
[AGENT][NEUTRAL] You know, a diagnosis of a sprain or whatever. Um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Then I would say yeah, OK, let's let's go back on that and pay it um it says again patient instructions.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Acute knee pain, muscle cramps, and spasms. No mention of a sprain or a contusion. He again says, I believe your knee pain is secondary to either a mild sprain or possible contusion, but that is not, it was not confirmed. So they did not right. So they didn't diagnose it. They just said that he was having pain and cramps and spasms. So because there's not an actual diagnosis of an injury, even
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Nothing definitive. Mhm.
[AGENT][NEUTRAL] You know, cause a contusion, all it is is a bruise.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] But they did not definitively diagnose him with that. The only definitive diagnosis is pain.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that's just not payable. Now, if you need, I mean, if, if you've kind of already given that and you need me to reiterate, I'm happy. OK, yeah, I can.
[CUSTOMER][MIXED] Yeah, I, I would really appreciate that. Yeah, because again I think [PII] kind of broke it down a bit because again it does seem she didn't go quite as in depth with I I really do appreciate you walking me through that too. I mean it's very interesting. I like learning about that stuff too, um, but as far as you know, yeah, it just seems like it's just pain so I did tell him that he just kept mentioning his knee and what he submitted, so I don't wanna say anything if it's not right, so that's why I just rather reach out to y'all.
[AGENT][NEUTRAL] Yeah, of course.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, of course.
[AGENT][POSITIVE] Yep, no problem at all. I will do what I can.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I appreciate you so much thank you. Are you ready for him now?
[AGENT][POSITIVE] No problem.
[AGENT][NEUTRAL] Yeah, go ahead.
[CUSTOMER][POSITIVE] OK thank you I hope you have a great rest of your day.
[AGENT][POSITIVE] You're welcome. You too.
[CUSTOMER][NEUTRAL] Alright, bye bye.
[AGENT][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Mr. [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hey this is [PII] with the clients department how are you?
[CUSTOMER][NEUTRAL] All right, ma'am, how are you doing?
[AGENT][NEUTRAL] I'm good um so [PII] was transferring um you over because she stated that um you were in disagreement with the um denial of your claim and audit kind of being upheld, is that correct?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK. Um, so what, what can I help you? Like, what questions or issues are you having exactly? So that I can kind of better explain on our ends.
[CUSTOMER][NEUTRAL] Both, both
[CUSTOMER][NEUTRAL] Well, ma'am, the reason they said that there is no uh there is no evidence that the injury was due to an accident.
[CUSTOMER][NEUTRAL] And uh that was the first time that I sent the paperwork in so I went in and got all the physician orders.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And, and, and what not, uh, for that injury, uh, for that, for that day when it happened, and I submitted it and it clearly says on there it was an accident.
[CUSTOMER][NEUTRAL] So, and
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You know, uh, like I said, first time they told me there was no, nothing, you know, saying or stating that there was an accident that occurred.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And uh got the other detailed information is 2 cents on there was a, you know, slip and fall injury.
[AGENT][NEUTRAL] OK, all right, so I have looked over the documentation you submitted. Thank you for that, by the way, because that does help because sometimes whatever they diagnose you with they do add additional information that a lot of times we can use so that was appreciated for sure um so I see that on the original claim that was submitted the diagnosis or sorry the um.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] remark code that they used states that there was no accidental bodily injury. So per your policy, you know, that's physical damage that was sustained to your body. Um, that could be a fracture, it could be a sprain, it could be any number of things. Um.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And so based off of what we had received that was not indicated so when the so I've gone in and reviewed and have looked at what was submitted and here's the issue.
[AGENT][NEUTRAL] There are a couple of places in here where the physician states that he thinks it could be a sprain or it might be like some deep bruising on your knee from where you had slipped in the shower. Um, but the definitive and final diagnosis was pain.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And based off of that diagnosis and what they were certain of, um, it doesn't meet your policy definition as an injury. It's not, we're not denying saying you didn't have an accident. It's very clear you did, obviously, because, you know, you're experiencing pain. You went in because of that, they confirmed, you know, the same, the same information that you were saying that you had slipped and hit your knee and twisted your back and stuff. They said the same thing.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] So it's not that an accident didn't occur. It's that based on the definition of injury, they did not definitively diagnose you with an injury. Um, just that essentially the fall hurt and they were treating you for pain more than um, than they were in actual injury. So that's where all of that, that's where our denials are coming from, um, is that it just, because they're
[AGENT][NEGATIVE] Their final and definitive diagnosis is pain and not an injury. Um, that is why, because it just doesn't meet our policy definition.
[AGENT][NEUTRAL] Does that make a little bit more
[CUSTOMER][NEUTRAL] So your policy is that the, um, because the the the the way I, you know, uh, the way it was explained to me, uh, the first time around it was that, you know, the fact that there was nothing on there that was an accident, uh, like you're saying, OK, there's no specific, uh.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Coating that I was on there was for the type of injury, but an injury did occur.
[CUSTOMER][NEUTRAL] You know, causing the pain and it was due to an accident. So, uh, you know,
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I don't I don't understand because uh.
[CUSTOMER][NEUTRAL] I guess the, the policy itself has, has changed.
[CUSTOMER][NEUTRAL] For being an accident, to, to now having to have detailed information on an accident you have and you have to have a, a type of bodily injury now, specific bodily injury or?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] The, the policy definition for this particular type of policy has not changed in many years. Um, I do apologize that the way that this was explained to you was, um, was not explained appropriately or clearly, um, because it is an accident policy. That is correct, um, because this does not pay for any type of sickness or anything like that. So anything outside of
[AGENT][NEUTRAL] Anything accidental um.
[AGENT][NEUTRAL] Is that is what this is for. However, to further go into that, um, what it pays for is injury or accidental injury or accidental bodily injury. So all of that falls up under 11 definition for this policy. And again, the definition is physical damage to yourself or any dependents that are insured.
[AGENT][NEUTRAL] That's sustained, of course, while your policy is in effect. And um it's the direct cause of you needing to seek treatment. It has to be clear of any disease or infirmity or anything like that. So, um, so the definition of an injury or an accident, um, an accidental injury is that you actually sustain some type of, I don't wanna say damage, but essentially some type of damage to your body.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] That was not due so like just to further.
[AGENT][NEUTRAL] If you would have had
[AGENT][NEGATIVE] God forbid. But it, let's say you had a stroke and you fell and you hit your head.
[AGENT][NEUTRAL] That while you did sustain bodily injury, it was the result of a stroke, which is a sickness. And even though there is bodily injury, that still would not meet our policy definition because it was the result of a disease or some type of bodily sickness. So you see how like, it's, it's very specific on the type of injury that it'll pay for and pain.
[AGENT][NEUTRAL] Qualifies more as sickness because it's the body's response to, you know, any number of things and it's not.
[AGENT][NEUTRAL] Injury based on the definition.
[AGENT][NEUTRAL] So that's why um it just doesn't meet the definition because they did mention also like the muscle spasms and stuff like that, and that's the only thing that they mentioned treating you for with pain and muscle spasms. They didn't mention how to care for a sprained back or knee. They didn't mention how to care for, um, a sprained or injured back or bruising or anything like that. They only mentioned the pain in the spasm. So it just doesn't need a policy definition because that's not an injury.
[CUSTOMER][NEUTRAL] So, so if, if, if I would have had bruising or had some sort of type of uh laceration or something, then that would have been, that would have been uh mean for.
[AGENT][NEUTRAL] That would, yes, sir. Mhm.
[CUSTOMER][NEUTRAL] For an accident, in other words, there's, there's physical, there's physical damage that's basically what was, even though the damage that, that, that occurred to me that night when I slipped the phone and fell in shower.
[CUSTOMER][NEGATIVE] That was physical damage.
[AGENT][NEUTRAL] Yeah, so if they would have said, you know, there's a very obvious, even if they would have said, you know, we don't see it like any external contusions or bruises on his knee or his back or anything like that. However, we feel that the pain is the result of, you know, a sprain or an, a deep bruise or a deep contusion, and that would have been your diagnosis. Yes, we would have been able to say, OK.
[AGENT][NEUTRAL] They may not be able to physically see that he has sprained it or that he has, you know, because all of his imaging is coming back clear. However, based off of all of his symptoms and everything, um, we do feel like this is the diagnosis. But they didn't say that. They said it may have been that, but ultimately diagnosed with muscle spasms and pain.
[CUSTOMER][NEUTRAL] So, so in other words, it, it all depends on the wording of the position.
[AGENT][NEUTRAL] And how they, yeah, and how they code it.
[CUSTOMER][NEUTRAL] On, on how position is is working, how he's working.
[AGENT][NEUTRAL] Yeah,
[AGENT][NEUTRAL] Or the coding that they put on the billing, yeah.
[CUSTOMER][NEUTRAL] The, the type of.
[AGENT][NEUTRAL] Yeah, so like I said, if you, if they would have said, you know, there's a bruise or a sprain or he has a small laceration, but he doesn't, you know, maybe it didn't need stitches, but there is like a cut or something there if they would have said any of that.
[CUSTOMER][NEUTRAL] Um, so
[AGENT][NEUTRAL] Then and, and put it as a diagnosis on how to care for that or if the billing would have mentioned that we could have said, OK, you know, they, he came in for pain but ultimately they do feel like he's, you know, he's sprained or strained his, his knee and, you know, his back or whatever, um.
[AGENT][NEUTRAL] Yeah, we could have looked at that and said, OK, that he came in for pain, but they did mention um and diagnose him with and tell him how to treat this other stuff, um, and we could have further evaluated for some benefits, but because.
[AGENT][NEGATIVE] It was just pain and spasms. It just doesn't mean our policy definition.
[CUSTOMER][NEUTRAL] So if I, if I'm able to get more, more information and submit some more information, um, can I still appeal the decision?
[AGENT][NEUTRAL] Yeah, you can do a second appeal, mhm.
[CUSTOMER][NEUTRAL] OK, that's what I'm gonna go ahead and do, ma'am. I'm gonna try to get more information.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and, and see if I can, uh, submit it, uh, as soon as possible, and, uh, we'll go from there, ma'am.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah that sounds fine we will absolutely take a look at anything that you can get and um if it looks like there's additional information that just wasn't included with the first round of stuff we'll look at it and we'll see if we can pay anything.
[CUSTOMER][POSITIVE] OK, ma'am. OK, I appreciate uh you explaining things, um, and, uh, we'll, I will try to get all that, uh, additional paperwork and submit it as soon as possible.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] No problem at all.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, alright.
[CUSTOMER][POSITIVE] Uh thank you, man. I appreciate it.
[AGENT][POSITIVE] You're very welcome. Have a great day.
[CUSTOMER][POSITIVE] You too as well, ma'am. Thank you. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye-bye.