AccountId: 011433970860
ContactId: 26f4aac6-b2c9-4a91-9caf-53214da8c34c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 767270 ms
Total Talk Time (AGENT): 212286 ms
Total Talk Time (CUSTOMER): 382270 ms
Interruptions: 3
Overall Sentiment: AGENT=1.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/16/26f4aac6-b2c9-4a91-9caf-53214da8c34c_20250616T14:48_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII] from the care team. I have an Emma Patino on the line for her husband [PII] for a claim. Um, the policy number is 2541395.
[CUSTOMER][NEUTRAL] Um, I tried looking at her documents and what she was trying to, uh, I think they were wanting more information on exactly, I told them about the preexisting condition waiting period, but I was unable to read some of those documents.
[CUSTOMER][NEUTRAL] Um, because it was a little blurry from the facts, and I was wondering if you could go over, um, more about what, what they're trying to file for. I, I couldn't read it. I couldn't understand her completely, but it looks like she filed a wellness claim form and a cancer claim form, and they both got denied because of the waiting period, um.
[CUSTOMER][NEUTRAL] And I, I don't know, I don't understand the waiting period part for
[CUSTOMER][NEGATIVE] The claim I couldn't read the documents well enough.
[AGENT][NEUTRAL] OK, give me just a second and take a look here.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And I went ahead and got a one-time authorization to speak to her from [PII].
[AGENT][NEUTRAL] OK, but she the policy holder?
[CUSTOMER][NEUTRAL] Uh, she is the policy holder.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And it's that last claim ending in 8247 and there's a bunch of them so I'm.
[CUSTOMER][NEGATIVE] I'm confused on how to go about that with that many being submitted.
[AGENT][NEUTRAL] OK. Yeah. I'm just pulling her information up here. Just, uh, just give me one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, do you have a callback number for her?
[CUSTOMER][NEUTRAL] Yes, ma'am, I do. It is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Oh, I'm ready for it.
[CUSTOMER][NEUTRAL] Oh, OK. Give me just one moment and I'll introduce you.
[CUSTOMER][NEUTRAL] [PII], are you on the line? Yes, yes, I am. I, I, I have [PII] from claim support. She'll be able to talk me through that claim, OK?
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Alright thank you so much uh huh uh huh you're welcome.
[AGENT][POSITIVE] Yes, good morning, Ms. [PII]. Uh, how can I help you today?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yes, uh-huh, um, I had filled out a, a claim form for my husband, um, because we just found out that he had, uh, uh, cancer, um.
[CUSTOMER][NEUTRAL] Oh, let's see, what was it? I think I wanna say it was.
[CUSTOMER][NEUTRAL] Uh, sometime last year, but I don't know what what the month was, um, but I was gonna see if, uh, if it was denied or, um, or considered preexisting or, uh, because I don't know if it was, uh, September, you know, because I already got the insurance in in September on [PII] it went into effect, so I just don't remember what day.
[CUSTOMER][NEUTRAL] He found out, you know, the news that he had cancer. So I was just wondering what, um, you know, what, what the status is on, on the cancer uh form that I had filled out.
[AGENT][NEUTRAL] Oh, sure, I'll take a quick look at that for you. Uh, do you mind if I put you on hold for just a moment?
[CUSTOMER][NEUTRAL] And, and sent to you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] No, no.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Uh-huh. You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Well I'll take it well I'll see if it send that but it's gonna come back.
[AGENT][POSITIVE] OK, I'm so sorry about that, Ms. [PII]. Are you still there?
[CUSTOMER][NEUTRAL] Uh, yes, so, OK, um, yes, uh-huh, I'm here. I'm sorry.
[AGENT][NEUTRAL] Uh yes, ma'am. Um, so we did, the claim was processed and released on [PII], and it does look like after we reviewed the medical records and also after a medical director review, it did indicate that the diagnosis was pre-existing.
[CUSTOMER][NEUTRAL] Yeah she was on hold.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Um, and so what that means is there will be a limitation period on the claim, um, until that he'll be able to file, um, file another claim, and it's a, a 12-month limitation period starting from the effective date of the policy.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Um, that limitation period will be over on [PII], and that's when he'll be able to start resume pro uh sending in claims for review for the cancer policy.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh, I see. OK. So, yeah, it was, I guess it was June, right? It was June when he had found, found out about it or when they did the, I guess, blood work or something and found out that his levels were high, his enzyme levels were high for, for cancer, I guess. So then, OK. So then, um, so it was within the, the, it, it wasn't pre-existing, right?
[AGENT][NEUTRAL] Uh, yeah, OK.
[CUSTOMER][NEUTRAL] I'm sorry, I guess, can you explain that to me again? Yeah.
[AGENT][NEUTRAL] Sure. So based upon the medical records, the elevated PSA results were present before the effective date of coverage, which that's what led to the additional testing that led to the cancer diagnosis. So, because it, it was the, the levels were seemed to be high prior to that effective date is what the preexisting conditions, the, the definition under the policy certificate.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Uh-huh. So, so what is that, um, so is he gonna be eligible for, uh, the cancer, uh, the cancer policy, um, the, the forms that I had, uh, filled out? Is he gonna be eligible for the, the money, you know, that if, if he, he had, uh, you know, if he, he has cancer, then it's supposed to pay out like $5000 I believe.
[AGENT][NEUTRAL] Um, so you would be able to, like I said, you, he would be able to file claims again on [PII] after that preexisting limitation period for the benefits under the policy certificate. Um, the first occurrence benefit.
[AGENT][NEUTRAL] Um, because it is pre-existing, would not be eligible for his claim, but the additional benefits under his policy, say like his cancer treatment, he would be able to file those after [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] After September after [PII] of this year, uh-huh.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, is he, uh, OK, so, so is that saying that he's gonna be eligible for the, um, to get the money?
[CUSTOMER][NEUTRAL] The $5000?
[CUSTOMER][NEUTRAL] That we had um that I had filled out the form for.
[AGENT][NEUTRAL] Right, so the lump sum benefit is not eligible if the claim is pre-existing.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] But the additional benefits under the policy for his the actual treatment of his cancer, he would be eligible to file claims for that.
[CUSTOMER][NEUTRAL] Oh, it's not gonna be
[AGENT][NEUTRAL] Like for, um,
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Um, radiation, chemotherapy, immunotherapy, hormone therapy, those, those things under the policy, he would be able to file for those after September.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, OK, for any kind of other, uh, um, um, yeah, oh, OK, I see, I see for treatments only, but he's not gonna be eligible for the money, uh, for the payout.
[AGENT][NEUTRAL] Uh, for the lump sum benefit, but not since it's preexisting, correct.
[CUSTOMER][NEUTRAL] Oh, OK, OK, that's what I needed to know. OK, I see. OK, alrighty, well that that's what I needed to know. Is there some uh something else that y'all can y'all can send me, I guess.
[CUSTOMER][NEUTRAL] Because, because I, I guess the, the explanation of benefits, it didn't, it didn't tell me that it just said that he wasn't.
[CUSTOMER][NEUTRAL] That, uh, the condition that that I was filing uh has been determined to be preexisting so no benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person's effective date. It just has a remark number 1 D1C0815. So I guess, I guess they're talking about.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The treatments too and also the, the payout, right? Does that cover both of those?
[AGENT][NEUTRAL] You're referring to the, the remark code on your explanation of benefits?
[CUSTOMER][NEUTRAL] Yes, uh-huh, yes, yes, I don't, I don't know what the yeah, the remote codes are. OK. All right, that's what I.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes, that, that one where it explains.
[AGENT][POSITIVE] Oh, I'm sorry.
[CUSTOMER][NEUTRAL] Yeah, yeah, that's what I was just wanting to know too, you know, because, um, yeah. OK, so then anything that he gets, OK, so any treatment that he gets for the cancer, uh, cancer treatments uh will be paid anytime after anything that happens after [PII].
[AGENT][NEUTRAL] Yes, ma'am. Um, any of the eligible benefits under the policy certificate, you submit the claims for the um itemized bills, um, and after [PII], then yes, we will be able to review those for benefits under his policy. Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It would, it would have met that limitation period.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Yeah, yeah. OK, I didn't, I didn't know there was a limitation period. I guess I didn't read the fine lines.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, yeah, if you look under when you're looking at your policy certificate under the, the policy schedule, uh, it should show like the preexisting language and also if there was a waiting period or um or that detailed information um on your policy.
[CUSTOMER][POSITIVE] Alrighty.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] OK, OK. Oh, I just thought it was effective the date that I got the the the uh the policy, so I, I, I didn't know. OK. Alrighty. Well, that's what I needed to know and I'll go back and read it again. Thank you so much. I appreciate it.
[AGENT][NEUTRAL] Uh, sure, Ms. [PII], was there anything else I could do to help you today?
[CUSTOMER][POSITIVE] Uh, no, no, that, that was all. Thank you.
[AGENT][POSITIVE] Yeah, sure, thanks for calling APL. You have a good day.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Uh-huh. You too. Bye-bye. Mhm. Bye.
[AGENT][NEUTRAL] Bye.