AccountId: 011433970860
ContactId: 35c1b12c-f835-4da9-951c-c69c60088391
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 841840 ms
Total Talk Time (AGENT): 245867 ms
Total Talk Time (CUSTOMER): 321536 ms
Interruptions: 10
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/35c1b12c-f835-4da9-951c-c69c60088391_20250428T21:10_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] [PII] this [PII] in the care team and I've got a member on the line that um we denied the claim and I was gonna see if you could kind of help explain why it's not covered because he he's just adamant that it should be covered because it's an accident.
[AGENT][NEUTRAL] OK, and what's the policy number?
[CUSTOMER][NEUTRAL] Policy number is 968817.
[AGENT][NEUTRAL] OK, just give me one moment.
[AGENT][NEUTRAL] For [PII], Mr. [PII]?
[CUSTOMER][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] It's the most recent policy or recent claim uh I got him verified. I've got a callback number.
[AGENT][NEUTRAL] OK, is that the callback number listed there on the screen [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes, it is.
[AGENT][NEUTRAL] [PII].
[AGENT][NEGATIVE] And he's upset, I take it.
[CUSTOMER][NEUTRAL] Yeah, he just doesn't understand why it's not covered. He just kept saying it's an accident. I mean, I see that it's a fall, but I was trying to look through the policy and see.
[CUSTOMER][NEUTRAL] Did it define some of these accident policies have like a list of everything but I'm not seeing.
[CUSTOMER][NEUTRAL] Yes I'm not really seeing that like they.
[AGENT][NEUTRAL] Well, yeah.
[AGENT][NEUTRAL] Even, even though it's a fault, we have to have an accidental bodily injury diagnosis, and it looks like the diagnosis is pain. So, therefore, the adjuster denied it as no bodily injury. So I'll pull up the claim documents and just verify that information.
[AGENT][NEUTRAL] Um, but you can go ahead and put him through.
[CUSTOMER][NEUTRAL] And you did say [PII], right? I'm just to make sure I uh heard your name right.
[AGENT][POSITIVE] Yeah, [PII] That's correct, [PII], mhm.
[CUSTOMER][POSITIVE] OK perfect I'll introduce you and then I'll release them to you thank you so much for your help I appreciate it.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK, Mr. Mr. [PII], I've got [PII] on the line. She's gonna help you and explain, uh, on this claim what's going on, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] Hello, Mr. [PII] sir. How are you? My name is [PII]. I'm in the, I'm in the claims support team. I'm taking a look at your documents now, so you'll just bear with me for a moment. So I understand you had, uh, had a fall and you went to the emergency room and you sent in a claim for that, for that incident.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and he got on there and said, was it due to an injury and it got, yeah.
[AGENT][POSITIVE] Correct, um.
[CUSTOMER][NEUTRAL] And what he got on the paper.
[AGENT][NEUTRAL] Right, and I'm looking over that information now.
[AGENT][NEUTRAL] And it does say in here that there was a fall. However, there, they have used the diagnosis of uh ankle pain and knee pain uh for the diagnosis itself in addition to the fall.
[CUSTOMER][NEUTRAL] They got phone.
[CUSTOMER][NEUTRAL] They got a phone.
[CUSTOMER][NEUTRAL] They got fall on there too. And they got, they got on there and said it was this due to injury. You see that fall?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes, however, they didn't give you a diagnosis of an injury. So this policy is very.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Ma'am, that they telling you that it's due to an injury. What do you mean? It it's telling you what it asked the question, was it due to an injury? It said yes.
[CUSTOMER][NEUTRAL] OK, a phone. What do you think a phone is? It got phone on there, it got, uh, uh, uh, knee pain, uh, uh, uh, ankle pain, and it got it got 4 things on there. So what you would you call it telling you what it's due to.
[CUSTOMER][NEGATIVE] They just self recover. It ain't nothing you can't get around it. They telling you what, and ask the question what they do to an engine. It got on there in black and white. So what, what, what, what you can't get around that.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] It tells you what it is, it's self. It asks the question what they do to is I see if it said no.
[CUSTOMER][POSITIVE] But it said yes.
[CUSTOMER][NEUTRAL] A phone, that's easy, man.
[AGENT][NEUTRAL] OK, I understand what you're telling me and I do see their paperwork that was provided to you by the emergency room department. However, the policy does state that it the the.
[AGENT][NEUTRAL] The policy itself, the.
[CUSTOMER][NEUTRAL] Ma'am, let me, let me speak to the manager. Let me speak cause you don't know what you're doing, because it's telling you in black and white and ask the question, was this due to an engine and if if if that thing asked me and telling you that it was due to the engine, that's what it would do.
[AGENT][NEUTRAL] Just
[CUSTOMER][NEUTRAL] Let me speak to somebody house and let me speak to so.
[AGENT][NEGATIVE] Right. I, I understand what you're saying, sir, and I can, I can get you to a manager if you'd like, but I'm trying to explain to you, but you don't wanna listen to what I'm trying to tell you. Unfortunately, it does.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] You know, it, it is, it is.
[CUSTOMER][NEGATIVE] Well, you didn't let me talk to somebody because it's it.
[CUSTOMER][NEUTRAL] Exp[PII] what you got to explain, ma'am, and telling you.
[AGENT][NEUTRAL] No, it doesn't indicate there's an injury, sir. It indicates you had a fall. It doesn't indicate an injury based on the diagnosis code. And based based.
[CUSTOMER][NEUTRAL] It's telling you what it's what. It ain't.
[CUSTOMER][NEUTRAL] Man say Indri and the the they say Indri.
[AGENT][NEUTRAL] Based on the
[CUSTOMER][NEUTRAL] It says, it says in.
[AGENT][NEUTRAL] OK, based on the policy.
[CUSTOMER][NEUTRAL] What is, what do
[CUSTOMER][NEUTRAL] It said, it said if it's an injury. It got on there, it said was this, was this business due to an injury? It said yes. So that means there was an injury.
[CUSTOMER][NEUTRAL] When you have a phone, that's an engine.
[CUSTOMER][NEGATIVE] I don't, I don't know where, I don't know what you, what you got going on. Give me somebody cause I say you, you, uh, you talking about you trying to, it ain't nothing to explain. It's self-slammatory. It tell you what it is due to an injury. You can't get around it. Now I selling insurance.
[AGENT][NEUTRAL] Sir,
[AGENT][NEUTRAL] I, I understand what you're saying, but the policy, your policy does state it has to be a bodily injury. And a bodily injury does not pain does not.
[CUSTOMER][NEUTRAL] I tell you show me.
[CUSTOMER][NEUTRAL] Well, I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's a that in ma'am.
[AGENT][NEUTRAL] That there is no bodily injury pain. It's not a diagnosis for a bodily injury. I'm trying to explain to you.
[CUSTOMER][NEUTRAL] It's that phone.
[CUSTOMER][NEUTRAL] Oh man, what, what, well, what is phone man?
[CUSTOMER][NEUTRAL] Man, what is phone? Huh? What you call a phone?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the fall is what, what occurred. However, you were not according.
[CUSTOMER][NEGATIVE] Give me somebody up there. Give me a manager, man. Let me talk to a manager. So see you, you try to, you trying to get around whatever, whatever, and it's self explaining telling you I can see if the thing said no. It asked the question, was it due to end. It's telling you that it was the end.
[AGENT][NEUTRAL] No, it indicates that you had a fall and it's pain, sir. It's not an injury diagnosis. And based on your policy, it has to be a bodily injury. And uh, you know,
[CUSTOMER][POSITIVE] You trying to be high top notch.
[CUSTOMER][NEUTRAL] It ain't saying no thing. It said in. It said in. What do, man? What dude the thing say it is telling you what it was.
[AGENT][NEGATIVE] OK, let me, um, let me get you a manager, sir, cause you don't even wanna let me speak and, and tell you, yeah. You know, Mr. Mr. [PII] yelling at me is not gonna help. I'm trying to explain to you.
[CUSTOMER][NEUTRAL] They tell you that it was in.
[CUSTOMER][NEUTRAL] You, you, you don't know what you're doing, ma'am. I tell it soon. I tell it soon, but, but, uh.
[CUSTOMER][NEGATIVE] You about to piss me off.
[CUSTOMER][NEUTRAL] You can't explain that to me because you trying to be top notch. That top notch stuff that you got going on, you you need to find something else to do.
[CUSTOMER][NEUTRAL] Cause I like I said, I tell you, I know it's supposed to be. I ain't just started this, man. Y'all got more look.
[AGENT][NEUTRAL] OK, there's no reason, there's no reason.
[AGENT][NEUTRAL] There's no reason to be cross with me, Mr. [PII]. There's no reason.
[CUSTOMER][NEUTRAL] Look, well, I tell you what, I'll tell you what, give me a man.
[CUSTOMER][NEGATIVE] Well, there ain't no reason for you to sit there and act like you don't know what you.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Uh, you, you're not even letting me talk. You, you're not even letting me speak. So just put, let me place you on hold and I'll get you a manager, OK? Let me place you on a hold.
[CUSTOMER][NEUTRAL] You trying to say these man.
[CUSTOMER][NEUTRAL] Oh for what?
[CUSTOMER][NEUTRAL] Ma'am,
[CUSTOMER][NEUTRAL] Give me a minute. Can you tell my name.
[CUSTOMER][NEGATIVE] You ain't talking about nothing. Give me a minute.
[AGENT][NEUTRAL] OK, hold on please.
[CUSTOMER][NEUTRAL] I like self-explained self-planatory. You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mr. [PII], I'm trying to reach a manager. It's a little bit late in the day, so if you'll bear with me for just a moment, I'm trying to reach someone for you, OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That sounds
[CUSTOMER][NEUTRAL] OK, OK, I'll see. You are on hold.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, Mr. [PII], I'm gonna transfer you to um to Ms. [PII], OK? Just one moment please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 3215
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hi, [PII]. I'm gonna um go ahead and bring him on.
[CUSTOMER][NEUTRAL] OK, sorry. I, I, I, I think there was a delay in the connection cause I didn't hear anything at first. I'm sorry.
[AGENT][NEUTRAL] That's OK. All right, um.
[CUSTOMER][POSITIVE] Alrighty ma'am.
[AGENT][NEUTRAL] And he's been verified he was transferred from the care team. He just doesn't wanna hear anything I have to say. I'm sorry.
[CUSTOMER][POSITIVE] No, you're trust me, it's not a problem whatsoever. I got his claim pulled up.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] But I know that this.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] This is me.