AccountId: 011433970860
ContactId: 4b401570-7001-4b43-aa4c-dc1c65055194
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 2055510 ms
Total Talk Time (AGENT): 857434 ms
Total Talk Time (CUSTOMER): 1113958 ms
Interruptions: 15
Overall Sentiment: AGENT=0.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/4b401570-7001-4b43-aa4c-dc1c65055194_20250226T17:32_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][POSITIVE] Hey [PII], I'm so glad I got you. Hey, you may not be, but I, I am glad I got you. Um, I have, well, he's a Spanish speaker. His policy number, let me give you the policy number, 18613997.
[AGENT][NEUTRAL] Hey [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII]?
[CUSTOMER][NEUTRAL] Yeah, [PII]. Now he's calling regarding the claims for Tatiana on part 3.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Part 3, OK.
[CUSTOMER][NEGATIVE] Now we denied them because of alcohol use. OK. So we went over that the policy does not cover, uh, you know, and of course it says addiction, so he's thinking we're saying she's an addict, but I, I explained to him, that's not, yeah, I mean, they're, they're in a bad situation. He lost his son, her brother back in September and his daughter, I'm just gonna cry. And his daughter, of course, is having, you know,
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Like a
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] I know.
[CUSTOMER][NEGATIVE] She's emotional. She's struggling. She's struggling, yeah. Oh my gosh.
[AGENT][NEGATIVE] She's struggling. Yeah, she's struggling to deal with it.
[AGENT][POSITIVE] God bless her. I can imagine.
[CUSTOMER][NEUTRAL] So, you know, I did go over the fact that he can submit an appeal, and he's just stating, is there anyone that I can just talk to? He said it would take 5 pages to really explain the situation by letter. So, his wife, I am just sitting here boohooing, his wife, [PII] speaks English and so they're just wondering if they can talk to someone, you know, maybe.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I mean, I know it won't do, but that's just what they need to do, that's what they need to do.
[AGENT][NEUTRAL] I was just gonna say, I mean, they, they can, and I will gladly listen if that makes their heart feel better. Yeah, but let me, I'm gonna, I'm gonna pull up this policy.
[CUSTOMER][NEUTRAL] And boohoo.
[CUSTOMER][NEUTRAL] Yeah, we did go over the exclusions. Yeah.
[AGENT][MIXED] I don't, I don't feel like it's wrong, but yeah.
[CUSTOMER][NEGATIVE] And this was just, she's not an addict. This is just her trying to deal with the loss of her brother.
[AGENT][NEUTRAL] Situational. Mhm.
[AGENT][NEUTRAL] I get that. I, and you know, it's hard because.
[AGENT][NEUTRAL] We, we, we can have sympathy, but we can't change the policy.
[CUSTOMER][NEUTRAL] Right, and he does he understands that, but he's just, you know, needing to explain. I think that, you know, with it being alcohol and, you know, I think they need to explain it. And I think that's what, I think they need this more by explaining.
[AGENT][NEGATIVE] It's so hard.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] See, and
[CUSTOMER][NEUTRAL] Then they need the claim paid if that makes sense.
[AGENT][NEUTRAL] Yeah. And you know, the thing is, like, if the exclusions read like for the treatment of alcoholism, I would say, OK, they're not really, they're, they're treating, I don't know. I mean, it says alcohol use unspecified. But if they, you know,
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Emotional.
[CUSTOMER][NEUTRAL] are treating her for emotional disorder.
[AGENT][NEUTRAL] Yeah, for right, like some type of emotional disorder and this was the result and all that, then that might be different.
[CUSTOMER][NEUTRAL] And we did discuss that as well, but he thinks that, and he thinks this is exactly what the reason behind this incident was. Of course it is, you know.
[AGENT][NEUTRAL] Oh yeah, I mean, and everybody deals differently. So like zero judgment here because I have no idea what I would do if my sister were to pass away. I have no idea. Um, let's see, I'm trying to.
[CUSTOMER][NEUTRAL] Me too, me too.
[CUSTOMER][NEGATIVE] Yeah, no. Mhm.
[AGENT][NEUTRAL] See here, because a lot of our policies will also say that so here's the thing.
[AGENT][NEUTRAL] Even if the alcoholism wasn't in there, the drinking of alcohol is an intentionally self-inflicted injury or sickness.
[CUSTOMER][NEUTRAL] Uh, you sure sure.
[AGENT][NEUTRAL] You, you know what I'm saying? And then some of them also mention it, uh, emotional disorders that are not an organic disease, and this is not, this would be.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] An emotion, well.
[AGENT][NEUTRAL] It's more of an emotional response.
[CUSTOMER][NEUTRAL] Yeah, that's how she's dealing.
[AGENT][NEUTRAL] Then it is, yeah, then it is an actual.
[AGENT][MIXED] Organic, my chemical imbalance is off. This is more of an emotional response. Um, like I said, I'm willing to listen. I, I don't think there's anything we can do though.
[CUSTOMER][NEUTRAL] Got you. Got you. So,
[CUSTOMER][NEUTRAL] Yeah, I don't either, but this is the closest thing to him writing an appeal I think, you know, and I'm gonna stay on the line just in case there's a communication.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Barrier, he said his wife. Well, I'll see, I'll see how, let me, let me get her on the line and see, see how she speaks English. OK, thanks. One moment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, gracisors Paciencia. The name of [PII] in La Laleia Conose, you know A espanolisque Vivianaablingles.
[CUSTOMER][NEUTRAL] Yes, it, yeah and it's a hosterapia, you know, we have casa.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] [PII], he's saying that his wife is in therapy right now and so she can't talk to anyone in English. Do you want to try to do it with me translating?
[AGENT][NEUTRAL] Um, I
[CUSTOMER][NEUTRAL] [PII]trair Siri.
[CUSTOMER][NEUTRAL] OK, OK, [PII]. OK, I, he said that if I can just translate, then he can answer any questions or and [PII] here quesapao can relamo issuiho issuiha, OK.
[CUSTOMER][NEUTRAL] Joliquela city was on area.
[CUSTOMER][NEUTRAL] Eusta Pianolamo illa polia tambien, OK.
[CUSTOMER][NEUTRAL] OK, la polisa, you see aelgoa so er.
[CUSTOMER][POSITIVE] I say look perfect er er er er a tale.
[CUSTOMER][NEUTRAL] Is the policy.
[CUSTOMER][NEUTRAL] He says that he understands that the policy doesn't cover drugs or alcohol.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But she's not an addict and this was just her, you know, her trying to deal with the loss of her brother.
[AGENT][NEUTRAL] So I guess my question would be since it is not the result of alcoholism, this was like an episode, if there is something a physician could write up for them where maybe it could be submitted for reconsideration.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and this, um, CAN no unaddicta.
[CUSTOMER][NEUTRAL] Calve is the considered algo de doctor or
[CUSTOMER][NEUTRAL] Do you know taro este is soloes.
[CUSTOMER][NEUTRAL] On
[CUSTOMER][NEUTRAL] Passion
[CUSTOMER][NEUTRAL] Macas.
[CUSTOMER][NEUTRAL] Yeah I see yeah mhm.
[CUSTOMER][NEUTRAL] See sitcom DKS.
[CUSTOMER][NEGATIVE] Nonadita.
[CUSTOMER][NEUTRAL] Pero conel lao lao el city was on the emotional.
[CUSTOMER][NEUTRAL] OK. Um.
[CUSTOMER][NEUTRAL] I don't know as soon as they soarta is uh not a meermolos was cigar.
[CUSTOMER][NEUTRAL] Repeat the number 451.
[CUSTOMER][NEUTRAL] So, uh, I call the medical person Shamala persona America Omica the cleva erlocumeta when I hit a [PII].
[CUSTOMER][NEUTRAL] I see stambien pueda stereo and el website conversation case specific okondolobo no specific.
[CUSTOMER][NEUTRAL] Uh, a key, a key if it's a car, but a key claim is.
[CUSTOMER][NEUTRAL] Mhm. So the necesita Nombre deea el numerra de la polia.
[CUSTOMER][NEUTRAL] Uh, and the Silas cos um.
[CUSTOMER][NEUTRAL] Esti Alon the brero play solomente unac uh on unsca or un accidente porque esa.
[CUSTOMER][NEUTRAL] Um. Exactly, exactly. OK, perfect. OK, so OK, Ms. [PII], OK, [PII], he's going to contact the doctor, her doctor.
[CUSTOMER][NEGATIVE] And try to get a letter, you know, from him stating that she is definitely not.
[CUSTOMER][NEUTRAL] An addict or um and doesn't use alcohol.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But in this case, due to her emotional distress, you know, just in this one occasion.
[CUSTOMER][NEUTRAL] That, um,
[CUSTOMER][NEUTRAL] And try to get that back to us so we can at least revisit the claim.
[AGENT][NEUTRAL] Yeah, cause I mean she's not even, she's not even [PII], so.
[CUSTOMER][NEUTRAL] Yeah, um, does he need to send in um.
[CUSTOMER][NEUTRAL] Maybe diagnosis codes.
[CUSTOMER][NEUTRAL] For that data service or?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Medical records or would anything else help?
[AGENT][NEUTRAL] If he can get any of that or all of that, every bit of information regarding this particular situation from her physicians would be helpful I think because it will, I feel like it will clearly identify that it's not.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alcoholism versus an emotional response to.
[AGENT][NEUTRAL] Loss, you know what I'm saying? So I would say if we, because I mean we have diagnosis codes.
[CUSTOMER][NEUTRAL] OK. Yeah.
[AGENT][NEUTRAL] Um, where it says alcohol use unspecified and then intoxication unspecified, so it, it just indicates that um she was intoxicated and then it's, um, and then it just says other specified health status. So those are the only two.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That I see um.
[AGENT][NEUTRAL] That's from Fire and Rescue.
[AGENT][NEUTRAL] Um, I'm assuming she went by ambulance maybe.
[CUSTOMER][NEUTRAL] Yes, yes, she did.
[AGENT][NEUTRAL] OK. Gosh.
[AGENT][NEGATIVE] Poor kid.
[CUSTOMER][NEUTRAL] OK, I know. OK, let me tell him. OK, A D C quelo mas informacion que pue conlojo Cre concilas notta de um la decita de la la sala de Hemegencia de de los sores.
[CUSTOMER][NEUTRAL] Uh, medical records.
[CUSTOMER][NEUTRAL] Um, OK, diagnosis kid the Nemos was corticos the diagnosis kitennemos solos on.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Well it is alcohol use.
[CUSTOMER][NEUTRAL] Not the name of Nada the.
[CUSTOMER][NEUTRAL] Lanemocional, not that there is a solemented as alcohol use.
[CUSTOMER][NEUTRAL] I like it it's a I mean the one emergencia it the um
[CUSTOMER][NEUTRAL] Bela la la person tendomoe esounach get so consumeddica primaria.
[CUSTOMER][NEUTRAL] Mama and creacion, yeah, que con um del del doctor or de los Doctorres in [PII] dear [PII] and Major.
[CUSTOMER][NEUTRAL] OK, we are from like it's so [PII].
[CUSTOMER][NEUTRAL] [PII]. Mhm. Your number the Lauter persona is [PII]
[CUSTOMER][POSITIVE] OK, perfect.e to la la titulaita is tell me who.
[CUSTOMER][NEUTRAL] in moments.
[CUSTOMER][POSITIVE] She now stambien bien and say yeah, you stabien.
[CUSTOMER][NEUTRAL] Uh, it is therapy um
[CUSTOMER][NEUTRAL] [PII] and [PII] both are in therapy. Could they submit claims for that?
[AGENT][NEUTRAL] Mm let me see if they have.
[CUSTOMER][NEUTRAL] It's it's check the CI beneficiar fortan here, OK.
[CUSTOMER][NEUTRAL] It says er lasanaindoapia uh porviaun uh nostopari que que argentina porquenosandemaso. OK, no, it's, it's OK, [PII], don't worry.
[AGENT][NEUTRAL] Oh OK.
[CUSTOMER][NEUTRAL] The tango unit uh tambien meter tambien yes all of that.
[CUSTOMER][NEUTRAL] The the the economy and I will not no, no, no, not the samosa in in on there.
[CUSTOMER][NEUTRAL] No, I'll say no, no, no, sir. OK, OK.
[CUSTOMER][NEUTRAL] OK, but in those uanos, um, uando puede configure informacion imitillo in a website or el Doepolifaxia lineformacion andotrus.
[CUSTOMER][NEUTRAL] This is [PII], OK.
[CUSTOMER][NEUTRAL] OK, bye.
[CUSTOMER][POSITIVE] OK, he's gonna work on getting all the oh my gosh.
[CUSTOMER][NEGATIVE] Just ripped my heart out.
[AGENT][NEGATIVE] I was just gonna say my heart is so broken because, I mean, I, you know, I don't know what he's saying, but
[CUSTOMER][NEUTRAL] You can hear it.
[AGENT][NEUTRAL] You can, yeah, you can hear the sadness in his voice.
[CUSTOMER][NEUTRAL] So, um, they lost his son last September and she's [PII] has had a really hard time dealing with it. And he said it's just this one time.
[AGENT][NEUTRAL] Yeah I mean she's young.
[CUSTOMER][NEUTRAL] You know, that she just couldn't, you know, she was just looking for some relief.
[AGENT][NEUTRAL] Yeah. Gosh. Um,
[CUSTOMER][NEUTRAL] But the wife and [PII] now are both in therapy.
[AGENT][NEUTRAL] Did I hear correctly that it was in [PII]?
[CUSTOMER][POSITIVE] They're from [PII] and they have a counselor from [PII] that has given them a good, a good deal.
[AGENT][NEUTRAL] They're from [PII].
[AGENT][NEUTRAL] Oh, so it's outside the [PII], yeah.
[CUSTOMER][POSITIVE] Well, he's here but he they're getting a really good deal, so.
[AGENT][NEUTRAL] 00, OK, OK. Was it, was it the, the young part [PII]?
[CUSTOMER][NEUTRAL] I didn't ask.
[CUSTOMER][NEUTRAL] I, I wanted to.
[AGENT][NEUTRAL] Because that's the only, that's the only other person on the claim.
[CUSTOMER][NEUTRAL] And he's still active.
[AGENT][NEUTRAL] As of right now.
[CUSTOMER][NEUTRAL] Let's see what 124.
[AGENT][NEUTRAL] Was it an accident or what? I mean, I'm, I'm not trying to be nosy, but like I'm just like.
[CUSTOMER][NEUTRAL] So, no, I know, trying to piece it all together.
[AGENT][NEUTRAL] Yeah, like, gosh, what on earth?
[CUSTOMER][NEUTRAL] What is um S06 let's see.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] I found a claim for him in September.
[CUSTOMER][NEUTRAL] Mm. Yeah.
[AGENT][NEUTRAL] Fracture of the skull.
[CUSTOMER][NEUTRAL] Yeah, that's probably him.
[AGENT][NEUTRAL] An accidental discharge from a firearm.
[CUSTOMER][NEUTRAL] Gosh.
[AGENT][NEUTRAL] The, oh gosh.
[AGENT][NEUTRAL] Oh God.
[CUSTOMER][NEUTRAL] Yeah, I'm sure that's him.
[CUSTOMER][NEGATIVE] It just makes me wanna cry.
[CUSTOMER][NEUTRAL] And they're both so young.
[AGENT][NEUTRAL] Very young. I mean, his birthday is in.
[CUSTOMER][POSITIVE] Oh my gosh. Oh my gosh. Oh.
[AGENT][NEUTRAL] Next week
[AGENT][NEGATIVE] I'm going to lose it. I'm going, this is, you know, this is one of those situations where while it's not as traumatizing, you almost can like put yourself in a situation of a 911 dispatcher because you're just like, I'm gonna need to decompress for a minute, you know, like I'm gonna need to walk away and have a good breakdown and come back and be like, OK, you know, like.
[CUSTOMER][NEUTRAL] Ah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Gee, that was a rough one.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] That was a rough one.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, I don't even know what I'll put in these notes, I mean.
[AGENT][NEUTRAL] [PII]. That is very, very young.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] I mean, I, I don't even know how to notate this right now.
[CUSTOMER][NEUTRAL] I just, my brain is blubber.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I'm just gonna put in here that um
[CUSTOMER][NEUTRAL] stating that his daughter is not an, an addict and she was experiencing the loss of her brother.
[CUSTOMER][NEUTRAL] And this is a one-time situation, um.
[CUSTOMER][NEUTRAL] I reckon I'm gonna state that we advised him to get medical records, um, any information from her doctor.
[CUSTOMER][NEUTRAL] That can support that maybe this was just emotional distress.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, let me go back to that policy because I was actually trying to see if I could.
[AGENT][NEUTRAL] Locate anything.
[AGENT][NEUTRAL] That would
[AGENT][NEUTRAL] This is one of those situations where it's like, what can I do? I wanna do something.
[CUSTOMER][NEUTRAL] I know.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEGATIVE] I am a wreck.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] It's definitely like I can feel my heart racing because I'm just
[CUSTOMER][NEGATIVE] Me too. I feel like my blood pressure just got up at that shot up, got up, shot up at 100%. Just trying to, oh my God.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] He said it's been so hard.
[AGENT][NEUTRAL] So here's my concern.
[AGENT][NEGATIVE] There's so many exclusions that this can fall up under.
[AGENT][NEUTRAL] Because the other one is being intoxicated.
[AGENT][NEUTRAL] And intoxication means that that which is determined and defined by the laws and jurisdiction of the geographical area.
[AGENT][NEUTRAL] So if her medical records come back with a high blood alcohol level, there's another exclusion.
[CUSTOMER][NEUTRAL] Well, I mean it's better to review everything, anything that we can get and just see if there's any.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Oh, yeah.
[AGENT][NEGATIVE] I mean, I want so badly to just be like.
[CUSTOMER][NEUTRAL] Let's pay it.
[AGENT][POSITIVE] Yep, like they've already lost one kid. It looks like they're well on their way.
[AGENT][NEUTRAL] God forbid
[CUSTOMER][NEUTRAL] You know that's gotta be in their mind.
[AGENT][NEUTRAL] Emotional, at least emotionally.
[AGENT][NEGATIVE] Losing another.
[AGENT][NEUTRAL] You know, because she's struggling. Thank God they put, they went to therapy like that was a very smart move. Um, that doesn't make it easy. And it's, and I, so I had a cousin that died in a car accident, um, 8 years ago, 7 years ago, 7 years ago. And anytime his birthday comes around or the week of his accident comes around, my aunt and his widow.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Call it hail Week because it floods all of those memories.
[CUSTOMER][NEUTRAL] Memories and feelings, yeah.
[AGENT][NEUTRAL] Both the good memories and everything that he's missed because his daughter was [PII] when he died.
[CUSTOMER][POSITIVE] Oh my gosh.
[AGENT][NEUTRAL] And his adopted daughter was [PII].
[AGENT][NEUTRAL] And now the adopted daughter is, she may have been older than that because she's in college playing volleyball and I think she's [PII].
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] And it's only been [PII].
[AGENT][NEUTRAL] [PII], so.
[AGENT][NEUTRAL] She was likely [PII] or [PII].
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Oh my God.
[AGENT][NEUTRAL] And now, you know, like I said, the
[AGENT][NEUTRAL] The younger the biological daughter is, she'll have a birthday in May and she'll be.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII] or [PII]?
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] So, I mean, it's just.
[AGENT][NEGATIVE] It's hard. And even after it's not been 6 months, you know, for them it's been years at this point and it's still so difficult. I mean, his widow all the time posts you should be here and she'll post memories of the girls and what they're doing and any adventures they're going on, and her hashtag is always you should be here, and he is tagged in everything.
[CUSTOMER][NEGATIVE] It's still hard.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] Oh my gosh.
[AGENT][NEUTRAL] Yeah, he was like a big brother to me.
[CUSTOMER][POSITIVE] I'm so sorry.
[AGENT][NEUTRAL] It's OK, I mean.
[AGENT][NEUTRAL] It was a freak accident. And you know, the, I think the, the hard part is not that he died in a freak accident. The hard part is that the reason why he died is because someone was trying to commit a crime.
[CUSTOMER][NEUTRAL] Uh uh.
[AGENT][NEUTRAL] So what they did, you know, like those gooseneck top trailers that have like the big huge hitch for like 1/5 wheel.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEGATIVE] Someone was trying to steal that from a business and
[AGENT][NEGATIVE] They didn't have the proper truck.
[AGENT][NEUTRAL] And when it came off the truck instead of turning around and trying to get it, they left it in the road and he hit that going about 65 miles an hour.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Oh my gosh.
[AGENT][NEUTRAL] Yeah, so
[AGENT][NEGATIVE] Because at the time, it's been changed since, but at the time, the road was not well lit and the trailer was black.
[AGENT][NEUTRAL] So he didn't see it until he was on it.
[CUSTOMER][POSITIVE] Oh my gosh.
[AGENT][NEUTRAL] But he was supposed to have both of his girls with him and they decided to go with mom.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Because they were in separate vehicles.
[CUSTOMER][POSITIVE] Oh my gosh.
[AGENT][NEGATIVE] Yeah, so it's just one of those things where it's like as awful as it is to lose him, we could have lost the entire family.
[AGENT][NEGATIVE] So you know, like you have to look for the silver lining or you know or whatever in the situation because we could have lost all of them and we only lost him, but that doesn't, you know, it doesn't make it easy, you know what I'm saying?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] But yeah, um.
[CUSTOMER][NEUTRAL] Why on this
[AGENT][NEUTRAL] I'm concerned, but about this one.
[CUSTOMER][NEUTRAL] Why on this, yeah, while on this emergency room visit is that only, only the diagnosis code for alcohol use? Why did they take her?
[AGENT][NEUTRAL] I noticed that like they didn't put anything.
[CUSTOMER][NEUTRAL] Why did they take her to the emergency room?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Because the only other thing that was on there that Z code was I think like.
[AGENT][NEUTRAL] Other health something. So it's like.
[CUSTOMER][NEUTRAL] Well, this is from, this is a UB from the emergency room and that the only thing they have on there was the alcohol abuse.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That's right.
[AGENT][NEUTRAL] It was the it was the ambulance visit.
[CUSTOMER][NEUTRAL] So why did they take her to the emergency room?
[AGENT][NEUTRAL] I think the medical records are gonna be helpful for this. I am concerned that those other exclusions are still going to apply because she was intoxicated.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] But uh yes, we can at least try and look and see.
[CUSTOMER][POSITIVE] But at least it's something we can try.
[AGENT][NEUTRAL] Because while the intoxication may play a part and still end up not being able to pay, maybe at least there will be an additional diagnosis that will.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I feel like for them it's not the payment necessarily, it's seeing that we're calling their daughter an alcoholic.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, and, and we went through that. He doesn't, he did understand it, but he did want to make sure that we knew that she was not an an addict.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Bless him, he didn't have to explain that to us.
[CUSTOMER][NEUTRAL] Well, I mean, yeah, so much of a spectrum of emotions and feelings. I just can't imagine, you know, and see if you think that the sounds, I mean, I sometimes I never know what to put in notes if it's too much or, you know, information.
[AGENT][NEUTRAL] I mean, I understand his reasoning, yeah.
[AGENT][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Uh, I will type a book, [PII], so let me tell you.
[CUSTOMER][NEUTRAL] Well, I'll put in here the insured call regarding claims on part 3 stating his daughter is not an addict. She was experiencing the loss of her brother at this time. It was a one-time situation.
[CUSTOMER][NEUTRAL] And was under emotional distress. And I'm just putting here a transfer call to [PII] and claims and translated and it was suggested that he get medical records and notes from doctors so we can review the claim, and that he was also advised of the appeal process.
[AGENT][NEUTRAL] Yeah, because like I said we can we can go back and review um.
[AGENT][NEUTRAL] But I feel like it's gonna have to be looked at more on an appeal basis than it would be.
[AGENT][NEUTRAL] On a let's reevaluate, you know, I don't know.
[CUSTOMER][NEUTRAL] And he, he.
[CUSTOMER][NEUTRAL] And he preferred talking to somebody versus
[AGENT][NEUTRAL] Yeah, I would put that just that because of the situation um he preferred to essentially appeal verbally.
[CUSTOMER][NEUTRAL] Like.
[AGENT][NEUTRAL] And that is like.
[AGENT][NEUTRAL] Where the records are coming into play, you know what I'm saying?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Just because there's a lot going on with the whole family due to the loss, you know.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So I'm just gonna put in here he did not want to submit a letter of appeal.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You know, it would be different if they knew that he, it wouldn't be different. They would still be in pain. But to know that he was like having some emotional issues and there was a reason for his loss, but
[AGENT][NEUTRAL] For it to be accidental.
[AGENT][NEUTRAL] Based off of the diagnosis codes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It's one of those things where it was like you almost can sympathize and understand when someone that's having mental issues does it because they feel like that's their escape, but when it happens by accident.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You're like
[AGENT][NEUTRAL] This shouldn't have happened, you know what I'm saying like.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then all of the what ifs and whys start running through we do need to.
[AGENT][NEUTRAL] I feel like we might need to let customer service know that he passed away from this accident that we have on file.
[CUSTOMER][NEUTRAL] But the only thing is is that I don't, I mean, he didn't say that it was [PII].
[AGENT][NEUTRAL] That's true.
[CUSTOMER][NEUTRAL] What if they have another, I'm sure it's him though.
[AGENT][NEUTRAL] Yeah, I mean, he had a skull fracture.
[CUSTOMER][NEUTRAL] It was in September.
[AGENT][NEUTRAL] It was in September. This is dated for September. This is an ER visit. It's a gunshot wound.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Like every everything.
[AGENT][NEUTRAL] Kind of points to it, but you're right, that would be making assumptions, so.
[CUSTOMER][NEUTRAL] Points to
[AGENT][NEUTRAL] I don't know
[AGENT][NEUTRAL] Other specified disorders of right middle ear and mastoid. I wonder if the way it hit him, it caused ear issues.
[AGENT][NEGATIVE] Gosh, gosh, respiratory failure.
[AGENT][NEUTRAL] Like those are all the diagnosis codes. That's not even like assumptions. Those are all the diagnosis codes.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] Like you said, it, it's pretty well pointing and that's the only other person on the policy, but I don't, that doesn't mean.
[AGENT][NEGATIVE] That they don't have more kids, maybe the other kid just isn't eligible. Like maybe it was an older brother that's just over the age of [PII] and we can't cover them anymore.
[CUSTOMER][NEUTRAL] Yeah, I don't know.
[AGENT][NEUTRAL] I don't, I don't know either, um, I don't want them to have to continue paying a premium on a child that may not be.
[CUSTOMER][NEUTRAL] Well, if it's family coverage, it, it wouldn't change, would it?
[AGENT][POSITIVE] It wouldn't change it. That's right, that's right.
[CUSTOMER][POSITIVE] Yeah. Yeah. Well, I'm sorry I got you, but I'm glad I got you cause I know you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I feel like we're kinda lighthearted.
[AGENT][NEUTRAL] Yes, yes. And I know this is heavy, so.
[AGENT][POSITIVE] Do what you've got to do to be OK. Take care of yourself, we're doing what we can for them.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] That's right. And I knew that you would.
[CUSTOMER][POSITIVE] Not just treat it as let's see what the policy says, but this is a person, so thank you.
[AGENT][MIXED] Oh, no, absolutely, of course, of course, always happy to. I hate that this is such a heavy situation, but.
[CUSTOMER][POSITIVE] You know, and, and he was, and, and I didn't tell you, I apologize, but he said that he was so appreciative of our time and our care and our concern, so.
[AGENT][POSITIVE] I, I really hope we can help the[PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] He seemed like a
[AGENT][POSITIVE] Like a good guy, you know.
[CUSTOMER][NEUTRAL] I did.
[AGENT][POSITIVE] Yeah. [PII] bless him. OK. Well, now, now I've got another name to add to my prayer list because goodness.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So, I know. All right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][POSITIVE] Goodness that.
[CUSTOMER][NEUTRAL] Isn't that the truth?
[AGENT][POSITIVE] Oh, OK, well let me know if there's anything else I can do if they reach out and they need something else and you got questions let me know. I'm happy to help if I can um I likely will not be the one that gets them when they're reviewed um or when they're submitted but if you are made aware of them being submitted and you want me to look through them, um, I'll do that too.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I won't know.
[AGENT][NEUTRAL] OK, I didn't think you would like I feel, I feel like we would just have to write down the policy number and just keep an eye on it, but um we'll see.
[CUSTOMER][NEUTRAL] [PII], if I did all, if I did that for all the ones that I.
[AGENT][NEUTRAL] That's what you'd be doing all day, isn't it?
[CUSTOMER][NEUTRAL] Right? That's what I've been doing.
[CUSTOMER][POSITIVE] Oh [PII], well, I, thank goodness it's my lunchtime and I can go breathe a minute.
[AGENT][POSITIVE] Oh goodness.
[AGENT][NEUTRAL] I know I was to say I've got like I've got like 5 minutes before mine so I feel you.
[CUSTOMER][NEUTRAL] Well, let's go take a lunch and breathe for a minute.
[AGENT][POSITIVE] Yes, absolutely, absolutely.
[CUSTOMER][POSITIVE] I appreciate you, [PII].
[AGENT][POSITIVE] You're very welcome.
[CUSTOMER][POSITIVE] And have a good day.
[AGENT][NEUTRAL] You too. All right, bye.
[CUSTOMER][POSITIVE] Thanks. Bye-bye.