AccountId: 011433970860
ContactId: 1ee84a66-ebbf-4f26-8b53-24b88eba3b2b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 963489 ms
Total Talk Time (AGENT): 240075 ms
Total Talk Time (CUSTOMER): 470206 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/1ee84a66-ebbf-4f26-8b53-24b88eba3b2b_20250514T15:28_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Good morning. This is [PII].
[CUSTOMER][NEUTRAL] And I had submitted a claim, um.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] That had a wellness thing for prostate um antigen screening. And I'd also included a hospital stay and a diagnosis for a specified disease policy. So I was I'll give you my claim number and let you see I got the one check I got was for the um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Screening, the uh prostate screening, but
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I really couldn't understand all of the descriptions or the remarks that are on the back, so let me start and give you my policy number if that is OK.
[AGENT][NEUTRAL] Sure, go ahead.
[CUSTOMER][NEUTRAL] OK. I'm, I'm looking at, at my book.
[CUSTOMER][NEUTRAL] Uh, and, um, it, it says at the top.
[CUSTOMER][NEUTRAL] Um, I'm just gonna tell you what this says. It says, it says cancer and specified disease policy, and it says guaranteed renewable for life, and the policy number on this sheet is 00408307.
[AGENT][NEUTRAL] OK, let me try that.
[AGENT][NEUTRAL] OK. And for security, may I have your date of birth and mailing address on file?
[CUSTOMER][NEUTRAL] OK, um, mine is [PII]. Um, my mailing address is [PII].
[CUSTOMER][NEUTRAL] You gave them your birthday.
[AGENT][POSITIVE] Thank you and let me have a callback number just in case we get disconnected.
[CUSTOMER][NEUTRAL] That's what she asked for.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so the claim is on the JSE.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Let me pull the details of the claim, OK? Let me pull the image.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] I didn't, I, I did not use a critical illness claim form.
[CUSTOMER][NEUTRAL] I guess I, I didn't think, yup, here is one. I didn't at the time know that I had one. So the original lady that I talked to said I could just use the form, the cancer form that I had on hand and uh fill in the information.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me check here.
[CUSTOMER][NEUTRAL] And I'm, I'm, I'm looking on this.
[CUSTOMER][NEUTRAL] I'll just let let you talk and then I'll.
[AGENT][NEUTRAL] I'm just reading right now what is under that um denial um and you're looking into the San Francis um benefit, correct?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] He, um, the critical illness, the specified disease policy, tuberculosis is one of the ones that is listed as a specified disease, uh, on page 9 of my policy book. And so I didn't even realize we had that and start until I started, uh,
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Uh, investigating and going through this book. And then I called, I, I don't know how many times I've spoken with somebody, but anyway, we got it all set up. I got all the records from [PII]. Uh, the, she told me to get a specific form from the hospital, uh, with the expenses. So I sent a copy of that form from [PII]. I can't remember the, the, the numbers on it, but it was a specific form that the hospital.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Gives you and I sent all of that and um so I don't know why it didn't I didn't get it uh maybe the check's in process for that but I didn't get anything for that.
[AGENT][NEUTRAL] OK, it has to be sent to the uh to the other policy, um, but let me see what we can do.
[CUSTOMER][NEUTRAL] Oh that city back there and I was not.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Yeah, when y'all when y'all send out these letters I know it's not your fault, but I, there's no way, uh.
[CUSTOMER][NEUTRAL] At my at my age can understand all the stuff that's on the back where you list uh the service descriptions and uh the amount that's.
[CUSTOMER][NEGATIVE] Uh, not paid, so, uh, you know, all, all, only thing he got paid for is the PSA test that I sent the, the billing for that, but he did not get paid so far unless it's being processed still. He got paid nothing for the specified disease policy and I sent all of that into.
[AGENT][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, it just needed to be divided into the two policies. Um, you know, whenever um a claim is sent in and there's just one policy number under that claim form, uh, it's just gonna run through that policy number and not go to any other policies unless it's indicated that it needs to go to another policy. So in this case, um,
[CUSTOMER][NEUTRAL] Well, it's all, it was all written out, it was, I had it all written on, on the thing, uh, like I drew through anyway, this, the policy number that I gave you covers cancer and specified disease policy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me go ahead and
[CUSTOMER][NEUTRAL] I mean there's not a separate policy number.
[AGENT][NEUTRAL] OK, um, I see.
[AGENT][NEUTRAL] OK, let me go with the examiner and see exactly what she can do about it, um, because I don't.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Not really sure what happened there.
[CUSTOMER][NEGATIVE] Yeah, cause she, he should have gotten so much for every day he was in the hospital.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Um, he should have gotten, uh,
[CUSTOMER][NEUTRAL] Something I think as a diagnosis for having one of those specified diseases and all of the medical, everything on that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, I see there's 18 pages. OK, yeah, let me get the examiner to look into this, OK? Do you mind holding for me?
[CUSTOMER][NEUTRAL] I, I don't mind.
[AGENT][NEUTRAL] OK, yeah, and the examiner is the processor, the one that processed the claim, OK? So let me get them on the line and see what we can do, OK?
[CUSTOMER][NEUTRAL] Yeah, because I
[CUSTOMER][NEUTRAL] You, you, you see what I'm talking about though, that
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, I see, um, yeah, yeah, I, I do see that. So, um, I'm just gonna try to determine since they're the ones that go over the benefits and see if it's something that is payable or not through the policy, and in this case they went ahead and denied. I just need them to look into it and see if it's something that they need to just go back and reprocess, OK? One moment.
[CUSTOMER][NEUTRAL] I mean, you understand.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Alright, you're from.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[AGENT][NEUTRAL] Hi [PII], how are you? This is [PII].
[CUSTOMER][NEUTRAL] Hi so how are you?
[AGENT][POSITIVE] Hey, I'm good and you?
[CUSTOMER][POSITIVE] Doing well thank you.
[AGENT][NEUTRAL] Good, good. Um, I have a member on the line, um, that she's calling because she believes that we did not process a claim, um, correctly. Um, so the policy number is 408307.
[AGENT][NEUTRAL] And it's gonna be on part one and Mr. [PII] and I have um Miss [PII], but Mr. [PII] is there as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me pull that up.
[AGENT][NEUTRAL] OK, this is the most recent claim.
[CUSTOMER][NEUTRAL] And then for Mr. [PII], right?
[AGENT][NEUTRAL] Mhm, yes.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Looks like a wellness claim for a couple different data service and he's saying we didn't pop up correctly.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yeah, she's
[AGENT][NEUTRAL] Uh, she, she or he is, both of them. They're looking for the San Francis Medical Center benefit, which is the hospital confinement benefit for 328 to 45. Um, she said that is a specified disease and that's what she was trying to get benefits for the specified disease benefit under the policy.
[AGENT][NEGATIVE] I went ahead and pulled the benefits and I do see that but uh yeah, I'm not sure exactly why I didn't pay or if it's something payable or what happened there. So um she's just confused. She, she said that she thought that she was gonna get that paid.
[AGENT][NEUTRAL] The payment for the specified is on that one.
[CUSTOMER][NEUTRAL] OK, let me
[CUSTOMER][NEUTRAL] Take a look.
[CUSTOMER][NEUTRAL] OK, I'm gonna pull the claim image up and um everything's been verified correct?
[AGENT][NEUTRAL] Everything has been verified. The callback number is the same one in the system.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And let's see, and that's the [PII]?
[AGENT][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, and this is for um.
[CUSTOMER][NEUTRAL] For [PII], correct?
[AGENT][NEUTRAL] Yes, [PII], but I have Ms. [PII] on the line. Again, Mr. [PII] is there as well. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so it's both Mr. and Mrs. [PII], OK.
[AGENT][NEUTRAL] You
[AGENT][NEUTRAL] Yes, mhm.
[AGENT][NEUTRAL] You're ready? Let me know when you're ready. OK.
[CUSTOMER][NEUTRAL] OK, I'm gonna pull up those claim documents. You can go ahead and send them through. Thank you. Everything's been verified, correct?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, you're welcome. Everything's been verified. OK. Yes, thank you. You're welcome.
[CUSTOMER][POSITIVE] Great. Thank you so much.
[CUSTOMER][NEUTRAL] Yeah, but what [PII] said.
[AGENT][POSITIVE] Thank you for holding and being patient for me, Mr. and Mrs. [PII]. I got Ms. [PII] on the line and she's gonna assist you with that claim, OK? She's an examiner.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] The processor. OK, thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hi, hi Mr. and Mrs. [PII], how are you? OK.
[CUSTOMER][NEUTRAL] My name is [PII]. I'm on the claim support team, so I'm taking a look at the documents now, so I understand there was a question about the um hospital confinement uh that was submitted.
[CUSTOMER][NEUTRAL] Yeah, yeah, it's, it's under the specified disease policy that we have and I don't know if you, if there is something that
[CUSTOMER][NEUTRAL] Uh, anyway, he had one of the specified diseases that's listed in the policy book, so that's and I sent in, I've talked to.
[CUSTOMER][NEUTRAL] I can't tell you how many different people, and I did everything they told me to do. Um, he had, his policy is, uh, in our book under specified diseases is number 28, tuberculosis. So when I told the previous person, she told me to get a specific form from the hospital, which I did, and I had that, it's it has initials down at the very bottom corner of the form.
[CUSTOMER][NEUTRAL] And I sent that in along with some other stuff from the hospital. So, um, I, it's my understanding that there are benefits payable for that. So now you can tell me why there is or is.
[CUSTOMER][NEUTRAL] OK, yes, so I'm looking at what you're looking at and I'm a little bit um.
[CUSTOMER][NEUTRAL] What I'm gonna need to do with this particular um claim, Mr. [PII], is I'm gonna send it back to be reviewed so he was um in the hospital from [PII], correct? those eight days looks like. Yes ma'am, yes ma'am. OK.
[CUSTOMER][NEUTRAL] And I had no idea.
[CUSTOMER][NEUTRAL] That we even
[CUSTOMER][NEUTRAL] There was such a thing, uh, in this policy book, and I don't know why. I was, I, I don't know why I was looking through it. Um, maybe to get some in a telephone number or something, and I just kept looking, but I didn't realize that we had a specified disease policy that was taken out in [PII], uh, but we do, so.
[CUSTOMER][NEUTRAL] Anyway,
[CUSTOMER][NEUTRAL] That's why I submitted all of this stuff for the tuberculosis.
[CUSTOMER][NEUTRAL] OK, so I'm just looking at some information, so bear with me for just a moment.
[CUSTOMER][NEUTRAL] OK.