AccountId: 011433970860
ContactId: 3db8fbe9-75a7-4302-833d-bab407ebe72b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 279619 ms
Total Talk Time (AGENT): 136968 ms
Total Talk Time (CUSTOMER): 105320 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.6, CUSTOMER=1.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/07/3db8fbe9-75a7-4302-833d-bab407ebe72b_20250107T19:25_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL this is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] over on the care team. How are you today?
[AGENT][POSITIVE] I'm good how are you?
[CUSTOMER][NEUTRAL] Doing all right, thank you. um, wanting some help, uh, regarding an accident claim. I've got the insured on the line. Uh, he submitted a claim originally stated it needed more information. He said he received or he did send that information. When I look at that claim though, it just says miscellaneous correspondence from insured and or provider. I'm not quite sure.
[AGENT][NEUTRAL] OK, what is that policy number? Let me take a look.
[CUSTOMER][NEUTRAL] Sure it is 991306.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Uh, give me just a second here.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] For [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, that's the 354-600-03?
[CUSTOMER][NEUTRAL] Yes, um, and I did, I did see that it referenced it said educational claim and I saw the original claim, um.
[CUSTOMER][NEUTRAL] But he said that this one was supposed to be that additional information we needed.
[AGENT][NEUTRAL] OK, let's see here.
[AGENT][NEUTRAL] OK, he sent an appeal.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] Did he send the information we needed or did he just send.
[AGENT][NEGATIVE] Um, because page 2 states, I, [PII] am disputing my denied accidental insurance claim. I went to the ER because I accidentally slipped on water in the shower that caused me to land and hurt.
[AGENT][NEGATIVE] My left knee and twist my back awkwardly.
[AGENT][NEUTRAL] I'm sending more detailed information on the accidental slip and fall that I had on [PII].
[AGENT][NEUTRAL] So he sent an appeal, um, the claim number 3514276. Let's take a look here.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Which, that one, it states no accidental bodily injury.
[AGENT][NEUTRAL] OK, so let's see.
[AGENT][NEGATIVE] Uh, sorry, I'm sick as a dog.
[CUSTOMER][NEUTRAL] No, no, you're fine.
[AGENT][NEGATIVE] I'm just not with it today.
[CUSTOMER][POSITIVE] Oh, it's I think everything is going around shoot, might have to, I think they're talking about possibly another mask mandate and all that fun stuff.
[AGENT][NEGATIVE] Oh [PII], I haven't heard that. I've been to urgent care. My primary care can't get me in. They're like full. I've been to urgent care 3 times in 5 weeks.
[CUSTOMER][NEUTRAL] Oh man.
[CUSTOMER][NEUTRAL] Oh, that's why I'm not looking forward to my son going back to school cause I was like we'd be fine if we just stayed here, but he's gonna catch everything there and bring it all back here.
[AGENT][NEUTRAL] Yeah, I've
[AGENT][NEUTRAL] Yeah, no, I've had flu, rhinovirus 2 days prior to [PII] and then 2 weeks later, I, I had COVID. And then yesterday, I went back and my right lung is full, it fluid, an infection, and it's, I'm wheezing. And then now I just have a viral infection. And let me tell you what, this right here that I have beats everything I've ever had in my life.
[CUSTOMER][POSITIVE] Oh my gosh.
[CUSTOMER][POSITIVE] And you're still working. You are a superhero. What are you doing?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] I woke my husband up the past two nights crying because I'm hurting so bad.
[CUSTOMER][POSITIVE] Oh my gosh. So, you need to take care of yourself.
[AGENT][NEUTRAL] Oh, OK, so on page 4 of this information that he sent, it states that the chief complaint is back pain and left knee pain, so there's no bodily injury. So that's why this appeal that he sent in, which states to state that he's disputing the denial. So the appeal was still denied. It was upheld. The original decision was upheld.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I guess I was more confused why it didn't state that.
[CUSTOMER][NEUTRAL] It was just his correspondence, but OK, I appreciate you looking at that for me. I'll go ahead and let him know and that was just simply because there, it was just pain, like there wasn't actually an injury.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEGATIVE] A bodily injury, yes, ma'am. This is a bodily injury accidental policy. So there's no bodily injury. Um, the diagnosis code, like I said, um, I wanna say page 4, it clearly states back pain and left knee pain. It does not state, um.
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That there's bodily injury done.
[CUSTOMER][POSITIVE] Got it. OK, I will let him know thank you so much take care of yourself. I hope you feel better soon.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Thank you bye bye.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.