AccountId: 011433970860
ContactId: 432ad869-75da-4082-a211-55ec60d78075
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 856960 ms
Total Talk Time (AGENT): 527014 ms
Total Talk Time (CUSTOMER): 335930 ms
Interruptions: 7
Overall Sentiment: AGENT=0.9, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/09/432ad869-75da-4082-a211-55ec60d78075_20250409T16:44_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hi, um, this is [PII] on the care team, and I have a broker on the line. They submitted a short term disability on behalf of a member and the claim is requesting medical records, and he had some questions on what what is needed, and I I can't exactly tell what's needed either, so.
[AGENT][NEUTRAL] OK [PII], um, what's the policy number?
[CUSTOMER][NEUTRAL] Uh, policy number is 2583002.
[AGENT][NEUTRAL] OK, just one moment.
[AGENT][NEUTRAL] For [PII].
[CUSTOMER][NEUTRAL] Yes, that's correct, and I have [PII] on the line from the OS Benefits Inc.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] And do you have a call back?
[CUSTOMER][NEUTRAL] I do. It's [PII].
[AGENT][NEUTRAL] And the patient information has all been verified, [PII]?
[CUSTOMER][NEUTRAL] Yes, it has.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] And it's on it um I see I see what it is OK um you can go ahead and transfer him and I will help him.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] You're welcome, [PII] have a great day.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thanks.
[AGENT][NEUTRAL] Hi [PII].
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Hi, my name's [PII]. I'm on the claim support team and uh Ms. [PII] transferred you over to me. You have some further questions about a claim for Ms. [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes ma'am, that's correct. I just, she, she's just come kind of reaching out to me because um we waited, she's been out of work I guess since the [PII], right? And for short term disability policies you'll have that 14 day probationary period so we waited that um I submitted on the [PII], um, and, um, it's just it's been taking a while and I guess you know.
[CUSTOMER][NEUTRAL] She's an older lady and I don't think she has a lot of savings in place per se so uh she wasn't able to pay her rent from March um because of this, so she was really hoping to bank on getting that short term disability pay out as soon as possible so that she doesn't get an eviction notice. um I'm just trying to figure out uh what's going on so I can kind of give her an answer to kind of put her at ease at least for the time being and I I noticed that there was a um or what [PII] told me was that.
[CUSTOMER][NEUTRAL] There's been like a um and a request for additional supplemental documents from the provider and uh I just I just need something to be able to tell her so that she can kind of um realize I'm doing my job for her and that these things just take time.
[AGENT][NEUTRAL] Right. Understood.
[AGENT][NEUTRAL] OK, alright, so I pulled up the documents I pulled up the claim form and so just let me just check some uh notes here so it appears that um let's see.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes ma'am
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So she should have received a letter um we uh processed the request for medical records on [PII], um, and what happened here is, um, [PII] her policy is effective for [PII], uh, for the disability, so, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What happens um in the event of uh when the, the effective date um being uh [PII], we have to do what we call um kind of a look back. And what that means is we need medical records to be able to provide for us that it wasn't a pre-existing condition prior to that effective date being [PII]. And then also, um, she, on the um documents that we received for the claim form.
[AGENT][NEUTRAL] Um, it does appear, um, let's see.
[AGENT][NEUTRAL] Looks like these were filled out by the physician.
[AGENT][NEUTRAL] Let me double check that. Doctor [PII].
[CUSTOMER][NEUTRAL] Yes ma'am, the attending physician statement.
[AGENT][NEUTRAL] Yeah, so they say that they first treated her for the condition on [PII]. Um, so we had to reach out to Doctor [PII] and get those medical records. And like I said, basically, they have that, um, it, it, it, it appears that it should be like a 12 month waiting period um for a pre-existing condition when these disability policies, but also because that um date of uh diagnosis does indicate that or condition.
[AGENT][NEUTRAL] Um, was prior to her effective date, it does, um, require us to reach out and get those medical records. So there was a letter sent to her on [PII] letting her know we did request medical records from uh Doctor [PII] and that's what we're waiting on currently.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but, but once you get that, that, uh, additional information, you'll be able to process the claim still correct, uh, because she has been paying into this policy or?
[AGENT][NEUTRAL] Well, it, yes, and I mean the claim will be processed either way now as far as what decision or determination that would be based on what uh the medical what the adjuster finds with the medical records um so like I said that's what currently we're waiting on so I mean the claim will get processed right now it's kind of in that pending status waiting for those medical records, um, so at this point we don't have any kind of determination as to whether the claim will be paid or not.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, and like I said, that's gonna be based on the information received from, uh, the inquiry to Doctor [PII]. So the claim will conti will be processed once we receive the medical records, and then that claim decision will be made. Um, it's just at this point it's kind of pending for that information.
[CUSTOMER][NEUTRAL] So basically, I'm sorry, I'm, I'm just trying to uh to follow exactly and, and I do appreciate your explanation. So basically you're telling me that if so did she, she got a surgery, correct? That was what was going on during uh I just wanna make sure.
[AGENT][NEUTRAL] It looks like, yeah, it looks like she had, um, let's see.
[CUSTOMER][NEGATIVE] It's hard to read this person's handwriting in my opinion, so it's just.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] It looks like to me, it does indicate she had, did she have surgery on [PII]. Is that right?
[CUSTOMER][NEUTRAL] She hadn't
[CUSTOMER][NEUTRAL] Yes ma'am, yes ma'am. So what, what I'm trying to follow is, is that you're telling me since she had symptoms in in [PII] that she wouldn't be able to use or be paid out her disability even though her policy started in in [PII], even if she didn't have a surgery for it prior, even though that she had symptoms for this condition.
[AGENT][NEUTRAL] OK. Yeah, I see that here.
[CUSTOMER][NEUTRAL] If I mean I, I'm just trying to follow that so like if she didn't have surgery dealing with it, yeah.
[AGENT][NEUTRAL] Yeah, I understand.
[AGENT][NEUTRAL] Right, so basically what happens is let me just get the policy here and let me read it to you right from the policy. So basically what, what happens, so if.
[AGENT][NEUTRAL] If it's um let's see.
[AGENT][NEUTRAL] Like I said, what the, the information that we received said that she was first treated for the condition in [PII] is what the paperwork says. So, um, and that's when it says that disability began.
[AGENT][NEUTRAL] So, and then it has, and that's um [PII], I'm sorry, it's [PII]. So even if that date wasn't in there, um, [PII], we would still request those medical records because again, we have to be able to verify that um under her policy, let me just pull this information up, my apologies.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEGATIVE] No worries, I just, my employees going to be pretty upset if we did all of this and she paid into this policy and then basically she's paying into it for nothing essentially is what you're telling me.
[AGENT][NEUTRAL] Well, not necessarily. Like I said, and that's why we have to have those medical records. It's, like I said, it does show that her condition or that date of diagnosis is [PII]. So basically, it could be um it could just be too that Doctor [PII] wrote that date in there because maybe.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] She came in there on that date, but basically what we're trying to establish is that the disability didn't begin prior to her effective date of [PII] because again the policy does um and what this means is like I said in the policy it states that um if there is a condition like I said we will look back for that 1st 12 months, meaning that um it's basically that preexisting limitation.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] So it says no disability will be payable if the disability is caused by or resulting from a pre-existing condition that would begin before you were continuously covered under the policy for 12 months. And so that.
[CUSTOMER][NEUTRAL] So, so, so let me ask you this, if he, if he were to put date of disability began, uh, [PII], there wouldn't be this issue is what you're telling me essentially.
[AGENT][NEUTRAL] Well, we would still, no, we would still be looking at the medical record request because like I said her policy effective date is [PII] and because that 12 month stipulation is in that policy, we have to be able to verify that it wasn't a condition that was prior to that effective date of [PII] because there is a 12 month, what we call pre-existing period or you know, like I said that that um that 12 month.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Back so basically like I said, if there was treatment for that condition prior to or effective date, then that might be considered preexisting but like I said, we don't really, we can't make that determination without having those medical records and at this point that's why it's pending for that information. So it's not necessarily that we won't pay it, it's just like I said, we have to be able to verify that it wasn't something that was preexisting.
[CUSTOMER][POSITIVE] Got you, got you.
[CUSTOMER][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] Definitely, well, not that that I really appreciate that. So if, if, if it does come out that it was prior and I guess that she can't, I guess use this policy, uh, we all let her know you'll, will you all send a letter of explanation, uh, explaining that to her essentially, or is that something that I should just go ahead and do? OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, well, now, do you have, excuse me, do you know, um, if she has access to, we do have a portal out there and it looks like the group, um, did you pro uh, did you submit the claim for her?
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][POSITIVE] Yes ma'am, yes ma'am, that is correct.
[AGENT][NEUTRAL] OK, OK, so there is a, um, we do have a um online portal where you can get the claim information a little bit quicker, but otherwise what would happen is, yes, once we receive that information, the determination can be made the claim will be processed through and we would um send it either you know she would receive obviously if there's.
[AGENT][NEUTRAL] Benefits payable she would receive those benefits so it looks like she is set up for direct deposit but if for some reason the claim is not payable, we would still send an explanation of benefits it would go out in the mail to her it would take a little bit longer but if she has a portal set up and she opts in, she could get claim information uh kind of quicker, do you.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][POSITIVE] Immediately, yes ma'am, no, I totally get that.
[AGENT][NEUTRAL] Right, do you know about that? Do you know about our portal?
[CUSTOMER][NEUTRAL] No, I, I, I, I do do most of our, um, well, yeah, yeah, yeah, I, I service this account all the time, so I mean I have the broker portal and then our, our employer portal as well, um, but, um, usually it's on the employees to set up their own APL account, correct? Right, so I, I think she's a little bit of the older generation. She is [PII] old, so she's not savvy tech savvy, right, exactly.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] That's correct, um.
[AGENT][NEUTRAL] OK, so she, yeah, she doesn't have computer.
[AGENT][NEUTRAL] We have a lot of those. I have, um, people in my family, they're the same way. They don't want those smartphones and they don't want, they don't want that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, no, exactly, and, and I.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Computers.
[CUSTOMER][NEGATIVE] Yeah they're stuck in their ways kind of thing now I'm, I'm so with you um I just, it, it kind of hurts my heart, man, that, that, um, she, she's paying into this and it could possibly not pay out for her, especially with her older age so um.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Now, also.
[CUSTOMER][NEUTRAL] Yeah, let me, let me just, let me just reach out to her and, and let her know what's going on uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I'll kind of try and brace her for if the claim doesn't pay out um you know, just, just I'm gonna say that's the worst case scenario. I'm not gonna say that that is gonna for sure happen, um, and, uh, I guess.
[CUSTOMER][POSITIVE] I guess uh I should have explained the policy a little bit more to her. I, I just, I really hadn't encountered this kind of issue before so um I guess this is also on me, so, um, I appreciate your time and, and you explaining this to me, and I'll reach back out to her and and hope for the best.
[AGENT][NEUTRAL] Certainly. And if you have any additional questions, [PII], you can always feel free to call us. She can contact us as, as, as well if need be. Um, but like I said, just kind of look out for that, um, that determination. Like I said, once we receive the medical records, it will go ahead and I'll continue to processing it just as when we received it.
[CUSTOMER][POSITIVE] Yes ma'am, yes ma'am.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, unfortunately, like I said though, because she's not on the portal, you can't opt in for those, uh, results a little sooner, um, but I would, um, if you'd like to give it a, um, let's see it was sent on 43, so it, it really just depends on that provider how quickly they answer our request when we send those requests out, um.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] But you're more than welcome to, you know, give us a call back and, and see if there's any change, um, maybe give it a week or so and then call us back if you don't hear something sooner.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] No I appreciate it, yeah.
[CUSTOMER][POSITIVE] Yeah, I, I, I will, I will for sure, um, I appreciate it you this has been very educational and, and thank you for your time, [PII].
[AGENT][NEUTRAL] You're welcome and uh [PII], did you have any other questions I can answer at this time?
[CUSTOMER][POSITIVE] No ma'am, no ma'am, that's it thank you.
[AGENT][POSITIVE] Alright, thank you for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][POSITIVE] Thank you, bye bye.