AccountId: 011433970860
ContactId: 3c86137f-4a5f-4380-aff3-a92e48a5fc1b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1205270 ms
Total Talk Time (AGENT): 350750 ms
Total Talk Time (CUSTOMER): 329806 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/3c86137f-4a5f-4380-aff3-a92e48a5fc1b_20250416T14:15_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Um, I have a question about filing a claim.
[AGENT][POSITIVE] OK, I'm happy to help. What kind of questions did you have?
[CUSTOMER][NEUTRAL] Um, first of all, where do I get the claim forms?
[AGENT][POSITIVE] So claim forms can be found on our website or I can send one to you if that's easier, but I'm happy to give you our web address as well.
[CUSTOMER][NEUTRAL] OK, I'll take that please.
[AGENT][NEUTRAL] Um, so it's [PII].
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, and how long do I have to file a claim?
[AGENT][NEUTRAL] Do you know what type of like insurance you have with us? Is it a secondary plan?
[CUSTOMER][NEUTRAL] Um, I'm not sure. It's just a hospital indemnity plan.
[AGENT][NEUTRAL] OK, so there's not a time limit um as far as uh a time you have to file the claim within. So as long as the policy is active, you can still file it.
[CUSTOMER][NEUTRAL] OK, um, also the summary of benefits says hospital admission benefit 3000 per day maximum of 1 day.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So I'm wondering.
[CUSTOMER][NEUTRAL] Um, like.
[CUSTOMER][NEUTRAL] There's just been one hospital admission right now that's what I'm filing on but it says maximum of one day is that per year or how does that work if we file it now?
[AGENT][NEUTRAL] Yeah. So usually on there, it'll say like per calendar year or something like that. Usually, it's for the calendar year.
[CUSTOMER][NEUTRAL] Had the
[CUSTOMER][NEUTRAL] OK, the only thing it just says is maximum of one day it doesn't say.
[CUSTOMER][NEGATIVE] Like ever or per calendar year or it doesn't give a time frame.
[AGENT][NEUTRAL] Hm. Do you have your policy number? I can double check.
[CUSTOMER][NEUTRAL] I do.
[CUSTOMER][NEUTRAL] It's 02010635.
[AGENT][NEUTRAL] OK, let me see here.
[AGENT][NEUTRAL] All right, and then for security, if I could just verify please your name and date of birth.
[CUSTOMER][NEUTRAL] [PII] [PII]
[AGENT][NEUTRAL] Thank you, [PII]. And then can you verify the address and email on file?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the email is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright
[AGENT][NEUTRAL] So yeah, hospital admission benefit, um, when I look at the schedule of benefits, it states 3000 per day, maximum of 1 day per calendar year per covered person.
[CUSTOMER][NEUTRAL] OK, and you're showing myself and my spouse covered.
[AGENT][NEUTRAL] I'm sorry, what was that again?
[CUSTOMER][NEUTRAL] Are you showing me and my spouse is being covered?
[AGENT][NEUTRAL] Yes ma'am, uh huh.
[CUSTOMER][NEUTRAL] OK, and then my next question is.
[CUSTOMER][NEUTRAL] Surgery in a hospital or outpatient facility or outpatient surgery center, um, what do they consider surgery? Like, is a heart catheterization a surgery?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Or no.
[AGENT][NEUTRAL] That's
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Or is that a procedure?
[AGENT][NEUTRAL] Let me see if I scroll back up here, if they give any sort of definition for surgery. Give me just a moment.
[AGENT][NEUTRAL] Hospital admissions this treatment.
[AGENT][NEUTRAL] Yeah, I mean, it just says we will pay the sur um accident and sickness surgery benefit per day when a surgical procedure.
[AGENT][NEUTRAL] Due to an injury or covered sickness is performed in a covered hospital or outpatient facility.
[AGENT][NEUTRAL] So it sounds like.
[AGENT][NEGATIVE] We will not pay benefits for preventative elective surgery.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] The exclusions under there, it looks like her hernia, adenoids, tonsils.
[AGENT][NEGATIVE] So it sounds like if none of that applies.
[AGENT][NEUTRAL] Then it would be something that would be covered.
[AGENT][NEUTRAL] Were you still there, [PII]?
[CUSTOMER][NEUTRAL] Can you hear me?
[AGENT][NEUTRAL] Oh, I can hear you now sorry I didn't hear anything before.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] I said who would know if that is considered a surgery or a procedure?
[AGENT][NEUTRAL] What was, um, what was performed again? I can double check. I'm sorry. I've forgotten what you had said the exact.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] A heart catheterization.
[AGENT][NEUTRAL] Heart catheter. OK.
[AGENT][NEUTRAL] Um, I can double check with somebody in the claims department to see if they can give me a little bit more insight if it's considered like a surgery or procedure. Do you mind holding for a moment?
[CUSTOMER][NEUTRAL] That's fine.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Is a heart catheter considered a surgery?
[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] Hey, this is [PII] over in customer care. How are you doing this morning?
[CUSTOMER][POSITIVE] Doing well sir thank you how are you?
[AGENT][POSITIVE] I'm good. I just have a quick question I'm hoping you can help with. I have an insured on the line who has an indemnity, excuse me, indemnity policy.
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] And they're asking me if a heart catheter is considered a surgery or like just a procedure.
[CUSTOMER][NEUTRAL] What type of can you tell me the policy number? like what type of uh indemnity do they have? Go ahead and.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, the
[CUSTOMER][NEUTRAL] Provide that
[AGENT][NEUTRAL] The policy number is 201.
[AGENT][NEUTRAL] 0635.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And give me one moment to take a look at their benefits.
[AGENT][POSITIVE] No worries.
[AGENT][NEUTRAL] Cause yeah, when I pulled it up they plan it looks like it just has a surgery benefit and she's wanting to file some claims and I wasn't sure if it was just a procedure.
[CUSTOMER][NEUTRAL] I believe normally it would so what happens under these is that usually that procedure code um that would.
[CUSTOMER][NEUTRAL] Uh, drive it, you know, drive that benefit. Now normally, um, it doesn't come through if it's being, and this is kind of a little bit deeper probably than you wanna be, but um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If the procedure, usually it's billed under the facility and they don't put it under surgery, so it's usually it is considered just a procedure, um, you know, because they don't bill it as a surgery.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, normally it will come in, um, on that claim form and it will be in like the, um, it will be a different revenue code other than a surgical revenue code if that makes sense.
[AGENT][NEUTRAL] OK. Right, right, right.
[AGENT][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] So it's, it is technically considered a procedure as opposed to a surgery I believe. I mean that that's usually like I said the way they come in under that um billing is that they would come in as a um under that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Procedure.
[AGENT][NEUTRAL] I'll yeah I'll just advise her of that and then of course tell her if you wanna go ahead and file it you can but this is the general consensus.
[CUSTOMER][NEUTRAL] Yeah, absolutely, and yeah she can uh by all means go ahead and have her, you know, just submit the claim, um, but just so that she is aware that it, you know, it could be uh denied for that reason, right, mhm.
[AGENT][NEGATIVE] Denied, right.
[AGENT][POSITIVE] OK, awesome thank you so much for your help this morning. I appreciate you.
[CUSTOMER][POSITIVE] You're so welcome, sir, anytime.
[AGENT][POSITIVE] Have a good day. Bye.
[AGENT][NEUTRAL] Thank you so much for your patience, [PII]. I'm sorry for the hold. Um, so in speaking with claims, she did say that normally when those things are billed over how they bill them, um, it does come through as a procedure. And so it's usually not billed as a surgery. You, of course, can file the claim. Um, worst thing that would happen is it's just denied and that would be the reason why.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, so, um, but the hospital benefit as long as he was admitted.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Then we should file that one.
[AGENT][POSITIVE] Yes, absolutely. And like, and like I said with the other one, it's totally up to you, um.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEGATIVE] You could file it, um, and then if it's denied, it's just denied, you know.
[CUSTOMER][NEUTRAL] And then we can file later if he were to have an actual surgery.
[AGENT][POSITIVE] Oh yeah, absolutely. Yes, ma'am. Like the denial one would not take away from anything that you're eligible for in the future.
[CUSTOMER][NEUTRAL] OK, and the hospital admission if it began as an ER visit, but he was admitted afterwards.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Does ER visit still count or because it's, it basically says hospital admission but he did go in through the ER.
[AGENT][NEUTRAL] No, I think let's see.
[AGENT][NEUTRAL] Let me see if there's any specifications on.
[AGENT][NEUTRAL] Emergency room let's see here.
[AGENT][NEUTRAL] Yeah, so if he went in through the emergency room, definitely file the emergency room because that's listed on there as well.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] I'm sorry, I have a ton of questions.
[AGENT][NEUTRAL] No, that's OK. Don't apologize.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Then another surgery um question it has surgery in a hospital and then it has surgery in a physician's office.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Surgery in the physician's office, does that include having skin cancer removed at
[CUSTOMER][NEUTRAL] Um, a dermatologist.
[CUSTOMER][NEUTRAL] In office
[AGENT][NEUTRAL] Let's see what this about.
[AGENT][NEUTRAL] Just.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] So I would say yes, because there's nothing under the exclusions or anything like that that talk about that not being a covered benefit.
[AGENT][NEUTRAL] As far as surgeries go that I just see that are not covered would be anything cosmetic.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, um, and my last question on that part is it's under um.
[CUSTOMER][NEUTRAL] Accident sickness surgery benefit.
[CUSTOMER][NEUTRAL] And it's got them separated in a hospital is 1500 in a physician's office is 750, but they both say maximum of one day is that you can file one for a physician, one for a hospital, or is it either or?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Surgery
[AGENT][NEUTRAL] It would be a benefit for each. So it's 1500 for surgery in a hospital, hospital outpatient facility.
[AGENT][NEUTRAL] Or free-standing outpatient surgery center, yeah.
[CUSTOMER][NEUTRAL] OK, so if we file.
[CUSTOMER][NEUTRAL] OK, so if we filed now for the skin cancer removal in a physician's office and then he actually has surgery um in a hospital or outpatient surgery center later this year we could file again.
[AGENT][NEUTRAL] Did I lose you?
[AGENT][NEGATIVE] Phone kinda cut out, Tonya.
[CUSTOMER][NEUTRAL] I said so if we file now for the surgery in the physician's office and then later this year he had surgery in a hospital or an outpatient facility, then we could file on the inpatient one.
[AGENT][NEUTRAL] If you can still hear me, you could do the um hospital one and the physician's office one, yes.
[CUSTOMER][NEUTRAL] OK, so can you hear me?
[CUSTOMER][NEUTRAL] Are you there?
[CUSTOMER][NEUTRAL] Ma'am, can you hear me?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Are you there?