AccountId: 011433970860
ContactId: 398bc817-0971-42c2-8b8a-fabbb0008f5e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 934450 ms
Total Talk Time (AGENT): 363178 ms
Total Talk Time (CUSTOMER): 557891 ms
Interruptions: 8
Overall Sentiment: AGENT=1.3, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/398bc817-0971-42c2-8b8a-fabbb0008f5e_20250108T13:38_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], um, I just got a notification that my claim was complete and from what I can tell online it looks like it was denied so I wanted to know, do I get any information on why it was denied?
[AGENT][POSITIVE] Well it would be my pleasure to assist you. Do you have your policy number available?
[CUSTOMER][NEUTRAL] Mm this is a confirmation number. I'm in the website right now.
[AGENT][NEUTRAL] It's gonna be your policy certificate number.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Or if you have the claim number, I can look it up by claim number.
[CUSTOMER][NEUTRAL] Alright, hold on, I do let me go back to that screen. I'm sorry OSC 91142.
[AGENT][NEUTRAL] OK, that's gonna be your confirmation number.
[AGENT][NEUTRAL] Did, did you receive a text message or?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Wait here I did, but here's my policy number. It's on that same line 1675649.
[AGENT][NEUTRAL] Thank you. And what is your name and date of birth, please, ma'am?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] And can you verify your date of birth and current mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] All right, thank you. And what is a good callback number, Ms. [PII], in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you. It looks like we have your work email. Do you mind verifying that as well?
[CUSTOMER][NEUTRAL] [PII] or do net. I don't know which one it flips to.
[AGENT][NEUTRAL] It's not or what we have on file.
[AGENT][NEUTRAL] You just kind of go with whichever one, right?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Is this on, is this on Eugene?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And did you receive a text message?
[CUSTOMER][NEGATIVE] I received a text that said your file your claim has been complete and when I look on here, the only thing I could tell that tells me it would have been denied is it says amount paid 0.
[AGENT][NEUTRAL] OK, did you click on the claim number to see if you can pull up the EOB? I don't know if you know that you have that option.
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] It's thinking says getting your file.
[AGENT][NEUTRAL] Because sometimes if you'll click on it, that explanation of benefits will come up and you're gonna receive one by mail as well.
[AGENT][POSITIVE] But that just for future reference. So according to the documents received and of course it's it's my pleasure to help you with this claim information or whatever you need today, um.
[CUSTOMER][NEUTRAL] Right, right.
[AGENT][NEUTRAL] Looks like.
[AGENT][NEUTRAL] Let me read this real quick.
[AGENT][NEUTRAL] Based on the information received, it does not appear that an accidental bodily injury occurred. Therefore, no benefits are payable.
[CUSTOMER][NEUTRAL] So I guess my question and maybe this is unders because before I filed it I called and spoke to someone and of course I understood that what she told me wouldn't be you are getting it or not getting it but I explained here's what happened. I don't even know if that falls under it and she's like, well I guess my question is because all of my husband's injuries were from a cut that he sustained, which was an accident.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me take a quick look.
[CUSTOMER][NEUTRAL] Like he he cut his finger building a fence on our property. Three days later we end up in the emergency room and then transferred to another hospital because of the infection from where he cut his, yes, so I guess my question is there was an accident that was the reason for it, or is it because it wasn't the, but it was the cut on his finger? I guess that's why I just want clarification.
[AGENT][POSITIVE] Oh my goodness.
[AGENT][NEUTRAL] Sure. And let me ask you, did he go for medical attention when he received the cut?
[CUSTOMER][NEGATIVE] No, because it was just a little, it was like just a cut working on fence. His finger wasn't falling off, cut it and then 3, yeah, like we're out putting fences on our property. He cut it putting up the fencing and then like the next day and the next day it kept getting redder, not healing. Well then it was like, oh my God, this is really bad, you need to go.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So it didn't cause us to go.
[AGENT][NEGATIVE] Oh my goodness, it was bad, wasn't it?
[CUSTOMER][NEUTRAL] Well, I mean, it wasn't bad when it happened, but I guess bacteria, you don't know what's in when you get a cut. So technically, the cut on the day it happened didn't land us in the hospital, but the cut is what caused
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Does that make sense? So I'm, I'm not sure if maybe that wasn't clear. I'm not sure if they don't, you know, or it's like, well no, it has to be from the cut that day, but the cut is what landed in there.
[AGENT][NEUTRAL] It does.
[AGENT][NEUTRAL] I understand.
[CUSTOMER][NEUTRAL] So I don't know. Just before I just kind of filed it I was like, maybe I need to call and ask because, you know, sometimes maybe it's not clear when they're reading it like, well, all those treatments, the treatment was from like sepsis, but it was because of the cut.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, tell you what I'm gonna and I understand, and it may just be that they don't have that specific information on the documents, so.
[CUSTOMER][NEUTRAL] That's what I'm saying. So before I just said, oh they, they denied it because I called before and I asked. Here's the situation because in my head I'm thinking, but and then I was like, wait a minute, was said you know what I paid for the insurance let me call and ask. And she's like if it was, she goes, and again I'm not saying she told me that is not the premise where I'm coming from. She just said well if the accident caused it, go ahead and submit it. But by looking at this, they may have looked at what that treatment was for.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Understand.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Like what does that have to do with the cut, but the cut is what, and on his emergency room paperwork, I don't know if that showed it, but you know, when you do intake, it was from that cut when he cut himself on the fence, but it wasn't the immediate cut that caused the problem. It was 3 days later the sepsis in his finger.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Right. No, I'm glad you called. Um, we'll be happy to take a look at it again.
[CUSTOMER][NEUTRAL] Because we have [PII], we have, we have [PII], there's dirt, there's stuff everywhere. It's just a matter of what bacteria I guess gets and stuff, so.
[AGENT][POSITIVE] Oh, you have goats. I love [PII]. I'm sorry.
[CUSTOMER][NEGATIVE] No, I know I had a fainting goat, but she died last year, and then mama [PII], we had to put to sleep. So I only had my two goats, so we weren't putting up the [PII] fence at the time, but I know they even changed his medication when they found out we had goats because I guess animal stuff can cause different bacteria, but it was definitely the cut didn't require the medical attention, but the cut caused the sepsis and did not heal and like we have pictures of it like it was disgusting.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] I was like, you've got to go, you're gonna lose your finger.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Yeah. Is, is it better now?
[CUSTOMER][NEUTRAL] No, it's healed up now, but like I said, he cut it and it, it wasn't even like a deeper it was bleeding and he had to come in. He just cut it. You wipe the blood on your pants, you go on, but then I guess.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It's like, you would never think. Yeah.
[CUSTOMER][NEUTRAL] No, but like I said, it kept on and I was like, you're, we're gonna have to go to the hos both my kids are nurses. We send the pictures they're like, uh, Dad, you need to go to the emergency room because I'm like, that's.
[AGENT][POSITIVE] Oh, that's nice. You have nurses in the family.
[CUSTOMER][NEGATIVE] I'm like, to my husband, I go, that's not gonna get better. So like I said, I get it, but if someone just looked at it, that maybe that part of it wasn't clear. The cut didn't land us there on the day, but the sepsis was caused from when the cut was made. I don't know.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Gotcha. Yeah, it was a result of the injury. Gotcha.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] I understand. Well, I'll tell you what I'm gonna do. I am sending this back to our claims team.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm putting in a request right now that they review that.
[AGENT][NEUTRAL] And
[CUSTOMER][NEGATIVE] And at least if they have all that in, you know what I'm saying, like maybe they glanced at, you know what I'm saying? They just looked at what was submitted and they're like, this wasn't an accident. This is sepsis being treated for sepsis, whatever it was, but the cut caused it.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Got you. I am putting in a request right now that they review that I will put that information in the notes as well.
[CUSTOMER][NEGATIVE] Yeah, I just wanna make sure that they've got all the information before I say yep, not get any money back from it.
[AGENT][NEUTRAL] And someone
[AGENT][NEGATIVE] Yeah, absolutely. No.
[CUSTOMER][NEUTRAL] I've had this policy for a long time, but I don't, I usually forget about it. My kids played sports and I pro I think only one time I've submitted for this because I just forget about it.
[AGENT][POSITIVE] Yeah, well, I'm glad you have it, you know, I mean, even if, um, you never know when you're gonna need it.
[CUSTOMER][NEUTRAL] I never know, but I wanna make sure I'm very clear if you don't go that day because of an accident like that changes things, you know what I'm saying? Like if the reason is the cut that day didn't land him in because there's a lot of things like what if you broke your arm and you don't go for a week? My daughter broke her wrist. We didn't know it was broken until a week later.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm. No, I think it's.
[CUSTOMER][NEUTRAL] Because she has a high pain tolerance like we didn't know, so that's important for me to know.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] Let me just, uh, so you're stating that the treatment was due to a cut on his finger while fixing your fences, yeah.
[CUSTOMER][NEUTRAL] And that
[CUSTOMER][NEGATIVE] And that's what I put in where I said describe the injury. I said my husband was working on a fence in the property. He's, you know, cut his finger and then we ended up three days later, but it, the cut caused the infection in the finger.
[AGENT][POSITIVE] Got you.
[CUSTOMER][NEGATIVE] That stupid cut. That was a very expensive cut.
[AGENT][NEUTRAL] It's just a little cut.
[CUSTOMER][NEGATIVE] Well, it was a very expensive cut. I mean, it was bleeding like he just wiped it, you know, if you work out on your property, you're not running up to the house every time you, but it wasn't like the finger was lopped off. But like I said, that definitely caused the whole trip was because of that cut.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] No.
[AGENT][POSITIVE] And I'm gonna ask them to give you a call. You should be receiving a call back within 24 hours. And what is a good call back number for you?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK. And then.
[AGENT][NEUTRAL] So he, he was diagnosed with sepsis due to the cut.
[CUSTOMER][NEUTRAL] I think that's what it was. I don't know, but I know he got lots of intravenous antibiotics and then we had to transfer the first hospital we went to his insurance covered that wasn't in network for him, but they had to transfer us for the bone specialist to make sure that the that it hadn't gotten in his bone.
[AGENT][NEUTRAL] Gosh.
[AGENT][POSITIVE] Oh my goodness.
[CUSTOMER][NEUTRAL] So we had to transfer.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] To a different hospital which was in a different network and that's the one that wasn't covered.
[AGENT][NEUTRAL] Oh man.
[CUSTOMER][NEUTRAL] But yeah, it was like the sepsis was like they had to keep doing X-rays and look at it and they had to have a a specialist look at it to make sure that it wasn't in his bone from the cut.
[AGENT][POSITIVE] You just never know from a little cut. Good grief.
[CUSTOMER][NEUTRAL] That the infection wasn't in the bone.
[CUSTOMER][NEUTRAL] You don't know.
[CUSTOMER][NEUTRAL] I know.
[AGENT][POSITIVE] Oh, I'm so sorry you had to go through that. I know that was just.
[AGENT][POSITIVE] Uh, you, you, it just probably turned your world upside down for a little while.
[CUSTOMER][NEUTRAL] Well, it
[CUSTOMER][NEUTRAL] I mean, I sent the kids to be with them. They're the nurses. I'm like, you go meet them there. I mean, the good thing was one of the hospitals is where my kids work. So the doctor's like, you can't do this.
[AGENT][POSITIVE] Oh, how, what a blessing. Yeah.
[CUSTOMER][NEUTRAL] So they are correct. It no, those charges aren't from a cut on the finger, but it was caused from the cut and it's, and like I said, it's important for me to know, does the insurance, if, if it's something caused from the accident or does it have to be something that right there lands you in the hospital?
[AGENT][NEUTRAL] Got it. And I don't know if you click on your policy number.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Your policy documents will download and you can actually review your benefits. Have you done that?
[CUSTOMER][NEUTRAL] Yep.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEGATIVE] I have, but like I said, when you read it and it says an accident and bodily injury, he had that. It was the cut and then the cut caused all these complications. So for example, if, if we would have went that day and they would have, he would have went to the hospital, it would be covered. This is a problem caused from the cut. It just didn't start causing an infection until 3 days later. Well, it started increasingly getting worse till 3 days. It looked like.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] Red and purple.
[AGENT][NEUTRAL] Got you. So what I have done, Ms. [PII], is I have submitted a request that they review the claim.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Also that they give you a call back after reviewing it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And at that number that you gave me?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] They will review that. I did put in the information that the treatment was due to.
[AGENT][NEUTRAL] An infection from the cut.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] While mending your fence.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that someone should give you a call back.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] Well, it has been such a pleasure to assist you. I'm glad his fingers better.
[CUSTOMER][NEUTRAL] Yeah, it is, but like I said, and I almost didn't, and I called and said it was called like that wasn't the cut wasn't necessarily treated, but it was the infection. I mean, I don't know so but like I said, I think it will be important for me to know when considering is what exactly is deemed an accident if it's something that has to send you that day because some things aren't it'd be caused from an accident so I will.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Got you.
[AGENT][NEUTRAL] Oh, I was
[AGENT][NEUTRAL] Yeah, I was gonna pull up your policy and let's see if there's a time frame for getting medical treatment, which
[CUSTOMER][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] It was just a couple of days later, wasn't it?
[CUSTOMER][NEUTRAL] It was 3 days later.
[AGENT][NEUTRAL] OK, let me check your policy documents, see if there's any language regarding the time frame to seek medical attention.
[CUSTOMER][NEUTRAL] I think I had, yeah, I think I had asked when I called but.
[CUSTOMER][NEGATIVE] Like I said, obviously I'm not one of those people. Everything that happens running to the hospital, get my money off these things. I've had this forever and I think one time I've used it. I don't know.
[AGENT][NEUTRAL] Me either.
[AGENT][NEUTRAL] Yeah, I'm not that kind of person either.
[CUSTOMER][POSITIVE] I even pay for the, I even have medical support in a separate policy that I pay so like that would have been covered, but that was covered from the hospital we went to because I even I even have that additional insurance.
[AGENT][NEUTRAL] Let's see, I'm looking under the benefits under part 2 under medical expense, accidental injury benefit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it states if as a result of accident bodily injury, the injured person requires medical treatment commencing within 60 days from the date of the accident.
[CUSTOMER][NEUTRAL] Yeah, and it definitely was that.
[AGENT][NEUTRAL] So that was, so you're in the time frame, so that's not going to be an issue.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right well I appreciate you checking that for me.
[AGENT][POSITIVE] So that's, that's good to know on that policy.
[CUSTOMER][NEUTRAL] Yeah right right well I guess I will wait for them to call me back and hopefully just kind of giving those notes we just make sure they've looked at it completely and not just oh this claim is for this that's not an accident. I feel like maybe they just looked at the documents and said that wasn't an accident.
[AGENT][NEUTRAL] Yeah, and then it might just be that they need another piece of document that does verify that it was due to a cut on his finger, you know.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Because I'm guessing I'm guessing the intake paperwork which we uploaded what they asked for, but the emergency room intake paperwork would show that I just don't know if it shows that what they asked for is your statements from the hospital that's not gonna state that that would be on the intake, you know, where you when you went so I may have to get that.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yeah, and they may need the medical records showing, you know, that he came in with a cut on his finger and, and found infection, yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, that's what I'm saying the intake paperwork mhm.
[AGENT][POSITIVE] Exactly. So it, it's probably just a, just a, just a piece of the puzzle missing, but they will look at it and if you need anything else, Miss [PII], you never hesitate to give us a call. We're here for you. And thank you for calling EPL. I hope you have a wonderful day as well. Y'all stay safe.
[CUSTOMER][NEUTRAL] Yeah all right well I'll wait when they give me OK.
[CUSTOMER][POSITIVE] All right thank you so much have a great day.
[CUSTOMER][NEUTRAL] Uh huh bye bye.
[AGENT][NEUTRAL] Bye-bye.