AccountId: 011433970860
ContactId: 44e30323-5ff8-424b-a989-9cf357dee183
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1192500 ms
Total Talk Time (AGENT): 636129 ms
Total Talk Time (CUSTOMER): 399000 ms
Interruptions: 8
Overall Sentiment: AGENT=0.1, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/27/44e30323-5ff8-424b-a989-9cf357dee183_20250527T15:17_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], yes, my name is [PII], and I was calling to find out what.
[CUSTOMER][NEGATIVE] Claims I should be filing for what I've been going through so I get my maximum benefits because I'm not getting paid well from work yet.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] First, uh, so what do you need from me? Um, the policy?
[AGENT][NEUTRAL] First, let me get a good callback number in case we get disconnected and then I'll get your policy number.
[CUSTOMER][NEUTRAL] Sure, my number is [PII].
[AGENT][NEUTRAL] OK, and policy number?
[CUSTOMER][NEUTRAL] Alright, the two policies I have is the accident policy, which is 244-515-7.
[CUSTOMER][NEUTRAL] And then the group hospital indemnity which is 244-517-5.
[AGENT][NEUTRAL] OK, we'll probably need to go one by one.
[CUSTOMER][NEUTRAL] That's fine.
[AGENT][NEUTRAL] Give me just a moment. Let me pull one up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I do apologize our system is running pretty slow, so give it just a moment.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] OK, [PII], can I get you to verify your date of birth?
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] Your address that we have on file and phone number or email.
[CUSTOMER][NEUTRAL] [PII]. Um, and what did you say my phone number [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] And let me see.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] It just kicked me out, so let me pull you back up, but you did get verified.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] Yeah, I think our system wants to take another 3 day break.
[CUSTOMER][NEGATIVE] Too many people around it at one time. They all probably got hurt over the weekend, right?
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEGATIVE] Well, hopefully not.
[AGENT][NEGATIVE] I hope not.
[CUSTOMER][NEUTRAL] Uh, I hope not. There's been a lot going on. It's been crazy up here in [PII]. Oh.
[AGENT][NEUTRAL] All right, let me see. So I have your accident policy.
[CUSTOMER][NEGATIVE] OK, so now the accident policy is for like, so I fell, I tripped over the thing which is a complete the curve, which is a complete accident. I broke my shoulder, right?
[AGENT][NEUTRAL] Mhm. Mhm.
[CUSTOMER][NEUTRAL] I, um
[CUSTOMER][NEUTRAL] went to the emergency room. I filed that claim under.
[CUSTOMER][NEUTRAL] Hospital.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, I do see that one.
[CUSTOMER][NEUTRAL] For the emergency room? Or do I, or am I able to collect it under both?
[CUSTOMER][NEUTRAL] I'm not like I'm not sure.
[CUSTOMER][NEUTRAL] Like when I had Aflac, I would be able to go in and put it for the accident in the hospital, but this is the first time I'm filing claims with you guys.
[AGENT][NEUTRAL] Let me check.
[AGENT][NEUTRAL] Yeah, cause your other one hasn't been processed yet, um.
[CUSTOMER][NEUTRAL] No, that was the first one I did over online, so yeah, but that was the only one I had an actual print out bill for, you know, and I'm not sure if it's because my services are still going on, but I have, I've had two other emergency room visits since that one.
[AGENT][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And, and a mission
[CUSTOMER][NEUTRAL] An observation in the ear of shoulder surgery. I had a lot going on. So I wanna make sure I get all the benefits that um require which um you know, signed up for.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me pull up your policy and see, um.
[AGENT][NEUTRAL] While I pull that up, since it is going slow, I will say it's, it's best to file, uh, if you think that it can go under both, file them for both, um, and if one gets denied, one gets denied, um, but I'm pulling it up now for your accident policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] And is my whole policy documents on the website as well for me to read?
[AGENT][NEUTRAL] Yes ma'am, so since you do have an OSC account, uh, you should be able to pull up your policy documents there. um, I have been hearing from some people that they're experiencing some technical issues with it. We are working on it. I don't know if it's up and running yet. I haven't had any anyone else say that they have.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] are having issues with it, but I just wanted to give give you a heads up just in case.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Yeah, so I was just wasn't sure, like, am I able to start like filing the claims with just the document? I have to get the doctor's signature? Do they get the doctor's signature on the forms or how does that work?
[AGENT][NEUTRAL] Um, if you're filling out the form to file, uh, you will want them to sign it and then you can upload it into the OSC. They will need to sign it, um, especially for the accident one. let me see, you do have a medical accident injury benefit.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] What is that?
[AGENT][NEUTRAL] For your accident benefit, and I do want to say that this is just a uh verification of benefits and not a guarantee of payment, but I'm looking at your accident policy and it is showing that you have um accidental and accidental injury benefit, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] As long as it was, you were, you needed medical treatment within 60 days from the date of the accident, which it sounds like you got treatment um immediately.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] It looks like if you were, if you had an injury for a covered expense and you had to go to the hospital emergency room, there was a $50 deductible that will apply for each injury.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] OK, what if it's the same injury that I had to go for?
[AGENT][NEUTRAL] Um, to the emergency room for each one?
[CUSTOMER][NEUTRAL] For the, if it was the same injury.
[AGENT][NEUTRAL] Let me see, because it's just showing a $50 deductible for each accidental injury, so it looks like just one, yeah, just one, yeah.
[CUSTOMER][NEUTRAL] OK, it is whatever. OK.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] You have a maximum benefit of up to $1000 for the medical expense um accident injury benefit that I mentioned earlier. Um, did you need to go through the ambulance at all?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Or stay in the hospital for more than 18 days.
[CUSTOMER][NEUTRAL] No, no ambulance.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, no, more than 18 days, no.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So it looks like you could file that claim.
[AGENT][NEUTRAL] Uh, under your accident policy.
[CUSTOMER][NEUTRAL] All right, and I don't have any like.
[CUSTOMER][NEUTRAL] Disability under this accidental claim, do I like, um, I know they denied me the accidental claim, I mean the um.
[CUSTOMER][NEUTRAL] Dis short term disability claim because of a preexisting condition at the time I filled it out, um, but I didn't know if like the accident one had it within there.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm not seeing it in your policy, um, and you can apply since if this is the one that you submitted for your hospital indemnity plan, you can file it for this one as well. It will be up to the examiner to make sure that they're covered.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, you also, and I'm, I'm just on your accident policy right now. I haven't looked at your indemnity policy yet. Um, so for your accident policy, I'm also showing a hospital admission benefit of up to $400.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And then, uh, did you have to go, you didn't have to go into intensive care, you just went straight into surgery?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, no, I was overnight, um, I had to do a cardiac clearance and then I went into surgery.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But then I wind up getting it then I was.
[CUSTOMER][NEUTRAL] Went to the ER the following weekend after the surgery and I was admitted for E. coli.
[AGENT][NEUTRAL] OK. That one will probably also be the $50 deductible um for the emergency room. So that was everything on your accident policy. I don't wanna get
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Confused and I pull them both up so that's why I'm going one by one, OK? And I do, I do see the one that you filed online so.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][POSITIVE] No worries. Now, once I was in.
[CUSTOMER][NEUTRAL] OK. That was the very first one. Then I had the um one where I went in through the emergency room with some like head pain due to the fall as well. And then they were making sure I was cleared enough to do the surgery. So that would be another $50 deductible as well. But then that, so that's a different ER visit and then the E. coli visit, correct? OK. All right. So, all right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm. Right.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And the E. coli one, they just, they didn't admit me. They kept me in observation.
[AGENT][NEUTRAL] And I will say
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] In the ER.
[AGENT][NEUTRAL] And I will say with all of these, so I do see the one claim on file should it get denied, you will see an explanation of benefits of why it got denied sometimes it's just because we need an itemized bill with procedure codes or um a primary insurance uh.
[AGENT][NEUTRAL] EOB, it just depends so don't just look at the denial as being denied um check and see and if you can't see the denial reason, uh, come to or call us back and we can check on that for you, um, because it doesn't always mean that it's denied because services aren't covered it could be that we just need more information, uh, so just keep that in mind.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me see about your.
[CUSTOMER][NEUTRAL] No problem. How long does it normally take to get the um claims back like a couple of weeks or?
[AGENT][NEUTRAL] Typically 7 to 10 business days, 7 to 10 business days, but because we did just have um a 3 day week and we might have some people out. That's not, that's not my department, so I don't know um how their coverage looks. It just depends, but rule of thumb, 7 to 10 business days. Um, give me one moment while I pull up your other policy.
[CUSTOMER][NEUTRAL] Or it's all depends.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The holidays
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and your hospital indemnity policy?
[AGENT][NEUTRAL] Has the confinement, let me see, you weren't confined.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now, I do see for this one that you have a wellness and diagnostic test benefit rider. So for diagnostic testing, per test, you get up to $250 which might help with that E. coli test that you were looking into. Um, I haven't heard of that one being denied or I, I haven't heard of anyone having that yet, so I can look into that. Um, but that is something that you would want to check for.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, is that per, per like, is that per, um, I'm sorry to interrupt you, but is that per, per test? So like every time I went to the doctors, he's been doing X-rays on my shoulder as well.
[AGENT][NEUTRAL] Uh, there's also a, mhm.
[AGENT][NEUTRAL] Per test.
[CUSTOMER][NEUTRAL] Or is that part of the accident policy? Like that's where I'm kind of confused to where what just put it in all and see what happens.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] That's what I would do, especially if you can maximize your benefits. I didn't see any diagnostic testing for the accident policy. I can look into that a little bit further.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, give me a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No worries, take your time. I mean, I mean, I know I'm all over the place. It's just been, I knew I had a call and it was gonna be a long conversation with somebody.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh
[AGENT][POSITIVE] Yeah, and, and my rule of thumb is when in doubt I just just file it for everything and they'll be able to help you and then.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Especially with as much as you're seeing and as much as you've done um and we don't do uh timely filing either so as long as your policy was active you can still file so say you found something um different or uh you had something towards the beginning when you had your policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, I still have last year's to file.
[AGENT][POSITIVE] Yeah, yeah, you are able to do that.
[CUSTOMER][NEUTRAL] I still have last year's I got to file for.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. Yeah, because I had a um catheterization done last year and then I was in the ER for stone, so I have a couple of things to do from last year as well, but I wanna get this done and then I'll go into that.
[AGENT][NEUTRAL] And let's see.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] One year at a time.
[CUSTOMER][POSITIVE] Exactly.
[AGENT][NEUTRAL] I do know the one for, if you were talking about uh [PII], it will more than likely, it, it'll be your hospital indemnity policy. Um, and let's see. Another part about your hospital indemnity policy, you have a wellness exam or test benefit of up to $75 per test. It didn't sound like you had a wellness exam. It was more of the diagnostic testing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, I have had wellness exams for both and then I also had a colonoscopy and endoscopy in February, and then, um, yeah, last year I had the mammography. I didn't put in yet, so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me see.
[CUSTOMER][NEUTRAL] I just gotta get the dates for all that and then I'll put them in there.
[AGENT][NEUTRAL] It looks like on your hospital indemnity policy you also have an annual first occurrence hospital rider of up to $500.
[AGENT][NEUTRAL] Which, let me see, I can get into that as well. Um, this would be the one to file for your shoulder surgery as well as you have a surgery benefit of up to $1000.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then anesthesia benefit of 25% of the surgical benefit amount.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Of what? 1000 or the whole amount of the surgical?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The surgical benefit amount, so of the 1000, the 1000. And let me go into the annual first occurrence, so I can be more.
[CUSTOMER][NEUTRAL] Of the 1000, OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And it looks like your hospital confinement benefit for this policy is it needed to be for at least 24 hours.
[AGENT][NEUTRAL] I know you said you spent overnight for one of them, mhm, so for this one.
[CUSTOMER][NEUTRAL] In the hospital.
[CUSTOMER][NEUTRAL] Yes, I was.
[AGENT][NEUTRAL] Yeah, it looks like as long as it was at least 24 hours you can get the hospital confinement benefit which I don't think I mentioned.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's just a hospital, it's a daily indemnity benefit of $30 per day.
[AGENT][NEUTRAL] So if you had to go in for both accident and hospital indemnity, I would file for both under this one because the confinement benefit, um,
[CUSTOMER][NEUTRAL] OK, I think I was from.
[AGENT][NEUTRAL] It's only $30 for this one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then the first occurrence hospital rider that I mentioned earlier, that's up to $500. The first occurrence is when you first went in for your shoulder, um,
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] The shoulder pain or the shoulder injury, not every time that you went in, just the very first time.
[AGENT][NEUTRAL] And for any other injury that you might have had,
[CUSTOMER][NEUTRAL] So would that be the
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Would that have been like when the first ER visit date or when I went in for the surgery?
[CUSTOMER][NEUTRAL] For the annual.
[AGENT][NEUTRAL] The first time you went into the hospital for your shoulder.
[AGENT][NEUTRAL] It'll get the $500. You'll be filing for all of these under this policy. Um, it sounds like for your shoulder surgery, you should be able to file under both of these, um, because it's an accident and it qualifies.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, that's what I was, I think I was thinking too.
[AGENT][NEUTRAL] So you'll be able to find both of these, yeah.
[AGENT][NEUTRAL] Yeah, um, but it's the first time you went in for that. So not every time that you went in for your shoulder. Um, any other injury you had, it's the first time you went into the hospital for it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and then every X-ray I had I could send in uh the report or whatever from the physician's office as well?
[AGENT][NEUTRAL] Right, you will also for either of these claims for both policies you will need an itemized bill or invoice showing procedure codes you might see procedure codes and unit numbers so yeah we'll need that one sometimes some hospitals don't give that to you they just give you a bill um sometimes you have to ask for it they do have them.
[CUSTOMER][POSITIVE] Appreciate the time.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, so if you get a bill from them and you don't see any kind of codes on there, you'll wanna call them and ask them if they can, uh, mail it or if you can go pick it up. Um, sometimes they won't just give it to you, you have to ask for it.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Alright, so with the codes on it, OK, CPT codes, right?
[AGENT][NEUTRAL] Right, it will need, it will need codes. Yes, ma'am.
[CUSTOMER][POSITIVE] OK, I appreciate your help.
[AGENT][NEUTRAL] So you know what you're doing. You know what you're doing.
[CUSTOMER][POSITIVE] Yeah, I appreciate it. I just wanted to double check to make sure that I was right with, you know, just trying to see what it was. OK, thank you so much for your time. All right, you have a good day.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] You're welcome. All right, thank you for calling ATL. Have a great day bye.
[CUSTOMER][POSITIVE] Thanks bye bye.
[CUSTOMER][POSITIVE] No problem bye bye.